Temperature Check Form
*Please note if you do have a temperature of 100.4 of higher or select yes to having any of the symptoms of COVID, you will not be allowed to enter the building and you will have to reach out to your supervisor and HR to receive further instruction.*
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Full Name
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First Name
Last Name
Email
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example@example.com
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Is your temperature equal to or higher than 100.4?
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Yes
No
Have you experienced any other COVID-19 related symptoms? Such as cough, chills, muscle pain, shortness of breath or difficulty breathing, sore throat, headache, congestion or runny nose, vomiting, diarrhea, new loss of taste or smell.
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Yes
No
Have you traveled outside of Connecticut in the past 14 days?
Yes
No
If yes, which state did you visit?
Are you vaccinated?
*
Yes
No
I prefer not to answer
Have you been COVID tested since your last shift?
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Yes
No
Have you notified your supervisor or HR that you've been COVID tested?
*
Yes
No
Please call your supervisor or HR before reporting to work.
Since you answered YES to either having a temperature of 100.4 or higher OR experiencing other COVID-19 related symptoms, please contact your supervisor and the HR team for further instruction.
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AM/PM Option
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Submit
Should be Empty: