GMBC Screening Checklist for Employees
Complete this questionnaire prior to your work shift
Name of the Individual
1) Today’s Date
_____________________
2. Have you been exposed to Covid-19 or do you believe that you have?
Yes
No
❗Restrict the individual from entering the building!
3. For employees - check the temperature and enter the result.
4.Please check any of the following Symptoms you (or other members of your household) are currently expressing?
Fever
Shortness of breath
Non-productive cough
Productive cough
Sore throat
Bronchitis
Respiratory infection
Nausea
Vomiting
Diarrhea
Severe fatigue (not related with travel, muscle or joint pain)
NONE of the above
Remind and ask individuals to:
Wash their hands or use antiseptics
Not shake hands or contact physically
Wear facemasks in the building
Submit
Should be Empty: