Employee COVID-19 Screening Checklist

Employee Screening Checklist
Date:
MonthDayYear
Date
Name:
First NameLast Name
Employee ID:
Initial Temp.
Initial temperature
Temp. @ 1
Temperture at 1 Minute
Temp. @ 2
Temperture at 2 minutes
Complete clinical questionnaire
Employee feels fine?
If no, explain:
Explain why the employee does not feel fine.
Are you taking any of the following?
Cold Medicine?
Antipyretics? (Aspirin, Ibuprofen, NSAIDs or Steroids)
Have you had any contact with anyone seriously ill of the last 48 hours?
If YES, explain:
Explain the contact with the seriously ill person in the last 48 hours .
Does the employee have any of the following symptoms? Check YES or NO
Cough?
If YES, explain:
Explain why the employee has a cough.
Sore throat?
Chills?
Digestive Issues?
Shortness of Breath?
Answer all NO = Employee Green Red / Yellow consult screening criteria
Screener Name:
First NameLast Name
Employee Result:
Sign here (If on phone or tablet use your finger to sign)
Clear
Completion Time
:HourMinutes
Should be Empty:

Employee Screening Checklist