Daily COVID-19 Screening
To be filled in the line up or just prior to Temperature Check up. DO NOT SUBMIT BEFORE TEMP Check. By Filling this questionnaire I consent to have my temperature verified by a Health Officer ( either with non contact or oral thermometer). I consent to have a member of the medical team contact me directly if more information are needed following completion if this form.
Date
*
/
Day
/
Month
Year
jj/mm/aaaa
Project Name
*
Jade Fever
Car Masters
Fresh, Fried and Crispy
Resident Alien
Project Home Security
UK Project
Lush
Bayer/Ibrance
Ozo
Project Solution
Project Pharma
Toyota FOB
Wells Fargo
Pillsbury
TALTZ
Lexus Project Bananas
Puddin
Project Estroven
Toyota Filmgroup
Ozo
Smarthome
Moon Powder
Dance
TEST
Select your project name
TIme
*
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Hour
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Minute
matin
après-midi
AM/PM Option
Identification
*
name
Surname
Email
exemple@exemple.com
Questions
1. Do you have a fever or a feeling of fever (chills)?
*
YES
NO
2. Do you have a cough?
*
YES
NO
3. Do you have difficulty breathing or chest pain?
*
YES
NO
4. Have you lost your sense of smell or taste?
*
YES
NO
5. Do you have any other symptoms that concern you? ( muscle aches, sore throat, headache, etc. ) If yes, please specify:
N/A
Did you take any fever medication in the last 6 hours ? ( Tylenol, Advil, etc.)
YES
NO
Temperature Check
Write down temperature reading provided by Medic
Body Temperature
Celsius
Type
Oral
Contact Free
Validation
Questionnaire validated by
*
Health Officer
Health Monitor
Self Assessment
SUBMIT
Should be Empty: