Covid-19 Daily Health Checklist
COMPANY NAME HERE
Today's Date
/
Month
/
Day
Year
1
Name
First Name
Last Name
Do you have a fever or chills?
Yes
No
Do you have a cough?
Yes
No
Do you have shortness of breath?
Yes
No
By entering my initials below, I certify to the answers in the above questions. At any time I start showing these symptoms, I will inform my employer immediately.
INITIAL HERE
*
Submit
Should be Empty: