KEC Staff COVID Questionnaire

Today's Date

Month Day Year
Hour Minutes AM/PM Option
KEC Staff COVID Questionnaire
Name *
Name *
Have you met anyone outside of your household without wearing a mask, eating or drinking, no matter the distance, indoors or outdoors since yesterday? *

No Yes
Have you or a member of your household been in close contact with anyone that tested POSITIVE for COVID? *

No Yes
Please DO NOT come in to work. Call Margarita at (808) 726-1309. Let her know when the possible exposure occured and she will advise you on further instructions.
Have you been wearing a mask outside of work? *

No Yes
Do you feel sick? *

No Yes

Have you had any of these symptoms since yesterday? *

Yes

Lack of Energy

Fever

Chills

Sore Throat

Cough

Diarrhea

Sinus Congestion

Runny Nose

Body Aches

Difficulty Breathing

Loss of Taste

Loss of Smell

Pink Eye or Itchy Eye