• COVID-19 Daily Health Screening Form

  • Date:
     / /

  • Do you have:

  • Fever within the past 24 hours?
  • Coughing/Sneezing?
  • Sore throat?
  • Shortness of breath?

  • And/or any of the following within the past 14 days:

  • Recent travel to high risk areas?
  • Contact with people infected, or diagnosed with COVID-19?
  • Resides in a community where community-based spread of COVID-19 is occuring?

  • If staff or visitors answer yes to any of these questions, do not allow them into your facility. Follow your facility’s protocols for what to do next. (A review by medical personnel should be available for questionable situations.) Please contact your supervisor if needed for additional guidance.

    *All completed forms must be saved.

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  • Should be Empty: