COVID-19 Questionnaire
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EACH employee will answer prescreening questions EVERY day or beginning of every shift.
Name
*
First Name
Last Name
Date
*
-
Day
-
Month
Year
Date
Email
*
example@example.com
Phone Number
-
Area Code
Phone Number
Complete a self check to ensure you do not exhibit signs flue like symptoms such as a fever, cough, or shortness of breath.
*
I completed a self check
I did not complete a self check
Do you exhibit signs flu like symptoms such as a fever, cough, or shortness of breath.
*
Yes
No
Do you have a temperature above 104 degrees?
*
Yes
No
Have you been in contact with a person infected with or suspected of having the COVID-19 virus within the last 14 days?
*
Yes
No
If you have recently (within 14 days) been in physical contact with anyone who has tested positive for COVID-19 please take appropriate self quarantine measures as recommended by the CDC (Center for Disease Control & Prevention).
*
I understand
I do not understand
Have you been advised by a medical professional or health organization that you should be subject to quarantine?
*
Yes
No
Do you have any reason to believe that you are unfit to perform your duties whether as a result of illness or injury?
*
Yes
No
Please notify your supervisor if you exhibit any of the above symptoms and stay home if you are sick, and promptly call a healthcare provider for advice if needed.
*
I Understand
I do not understand
Signature
*
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