Clone of COVID-19 Pre-Shift Health Screening

Name*

First NameLast Name

Position*

DriverDispatcher or Admin - In OfficeDispatcher or Admin - Work from Home *Complete only when coming in to contact with company property, customers or other staff

In the last 72 hours have you had a fever of 100.4° F or higher as confirmed by oral thermometer? or have you otherwise felt feverish?*

YesNo

In the last 7 days have you had any of the following symptoms consistent with COVID-19 that you cannot attribute to another health condition: cough, shortness of breath or difficulty breathing, sore throat, loss of taste/smell, muscle aches, headaches, chills, or repeated shaking with chills?*

YesNo

In the last 14 days has a member of your household isolated with a suspected or diagnosed COVID-19 case, or been sick with symptoms consistent with COVID-19?*

YesNo

Have you had close contact (within 6 feet for more than 10 minutes) with someone who is currently ill with a pending test or who has been diagnosed with COVID-19?*

YesNo

Have you had close contact (within 6 feet for more than 10 minutes) with someone who is suspected of having COVID-19 because they have had COVID-19 symptoms?*

YesNo

If you will be exiting your truck or office to come in to contact with someone closer than 6', do you agree to wear appropriate PPE and use sanitization supplies, as well as follow CDC Guidelines for prevention of the spread of contagious diseases?*

YesNo

If you answered "No" to all of the above questions you may resume your shift as scheduled.

If you answered "Yes" to any of the above questions, please call your supervisor immediately for further guidance.

*A forehead (temporal) scanner is usually 0.5°F (0.3°C) to 1°F (0.6°C) lower than an oral temperature. An ear (tympanic) temperature is 0.5°F (0.3°C) to 1°F (0.6°C) higher than an oral temperature.

If you are out of of PPE or sanitizing products, please contact:

Signature*