Employee Covid-19 Screening

1

Name* This field is required.

First Name

Last Name

2

Have you had contact with person with a confirmed or suspected case of Covid-19 in the last 2 weeks* This field is required.

YESNO

3

Do you have a fever?* This field is required.

YESNO

4

Do you have a cough?* This field is required.

YESNO

5

Do you have nasal congestion, sneezing, or symptoms of a cold?* This field is required.

YESNO

6

Do you have shortness of breath or difficulty breathing?* This field is required.

YESNO

7

Do you have chills?* This field is required.

YESNO

8

Do you have muscle pain?* This field is required.

YESNO

9

Do you have a headache?* This field is required.

YESNO

10

Do you have a sore throat?* This field is required.

YESNO

11

Do you have any new loss of taste or smell?* This field is required.

YESNO

12

Do you have nausea, vomiting, or diarrhea?* This field is required.

YESNO

13

What department do you work in?

14

You answered YES to one or more of the questions and are not permitted to enter the office.

Please submit this form and your immediate supervisor will be notified that you are experiencing symptoms of Covid-19 and will contact you for further instructions.