Staff Screening

Staff Name*

First Last

Email*

Select Site*

Do you have any of the following?

Fever - a measured temperature of 100.4F or greater*

Yes
No

Temperature

Shortness 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

Today's Date*

Date

COVID-19 Screening for Staff members

Do you have any of the following?

Subscribe

Links

News