COVID-19 Screening for Staff members Staff Name* First Last Email* Select Site*Select SiteS2S3S4Do you have any of the following?Fever - a measured temperature of 100.4F or greater* Yes No TemperatureShortness of breath within the most recent 2 weeks?* Yes No Cough* Yes No Chills* Yes No Muscle Pain* Yes No Sore Throat* Yes No Headache* Yes No Recent loss of taste or smell* Yes No Are you ill or caring for someone who is ill? (Employees who are well but who have a sick family member at home with COVID-19 should notify their supervisor.)* Yes No HiddenToday's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenDate Δ
