Chava' Pelo Salon Team Member COVID-19 Self-Assessment Form

Chava' Pelo Salon Team Member COVID-19 Self-Assessment Tool
In order to maintain a safer environment for our team members and guests, all team members must be screened using this tool before every workday shift, prior to entering the Salon. Team members are asked to self-assess themselves before they come to work. Once you arrive at the salon, please take your temperture with the touchless therometer (using gloves) and note your temperture below.
Team Member
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Daily Temperature Log : Start of workday temperature Note Temperture Here*
You must answer “NO” to all the questions in this questionnaire in order to enter the Salon. If you are experiencing any COVID-19 symptoms or answer “YES” to any of the questions, DO NOT come to the Salon. Immediately contact your health care professional for recommended next steps AND notify your team. Thank you for your cooperation.

STEP 1. SYMPTOMS

Rows	Yes	No
Do you have a fever (38* C or 100.4* F) or any COVID-19 related symptoms including: - cough - shortness of breath - sore throat - difficulty swallowing - hoarse voice - runny, stuffy or congested nose - lost sense of taste or smell - digestive issues such as nausea/vomiting, diarrhea, abdominal pain - fatigue - falling down more than usual - chills - headache

STEP 2. CONTACTS
Rows Yes No
A. Are you in contact with any known COVID-19 positive patient?
B. Have you tested Positive for COVID-19?
STEP 3. TRAVEL
Rows Yes No
Have you traveled to any known region with COVID-19 in the last 14 days?
Should be Empty:

Rows	Yes	No
A. Are you in contact with any known COVID-19 positive patient?
B. Have you tested Positive for COVID-19?

Chava' Pelo Salon Team Member COVID-19 Self-Assessment Tool