Diocese of Marquette: COVID-19 Screening Survey (Template)

Organization Name
COVID-19 Screening
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDateHourMinutesAM/PM Option
Employee Name:
First NameLast Name
Current Temperature:
In the past 24 hours, have you experienced:
Rows Yes No
Fever (felt feverish or above 100.4° F)?
New or worsening cough?
Shortness of breath?
Sore throat?
Vomiting, Diarrhea, or Chills?
Muscle Pain?
Sudden loss of taste or smell?
If symptoms are due to a known, non-worsening chronic condition, mark “No”.

If you otherwise answer “Yes” to any of the symptoms listed above, please do not enter this work site, or leave the work site and return home. Self-quarantine at home and seek a COVID-19 test. Contact your physician’s office for testing information, or contact your local COVID-19 testing site. Stay home until you receive advice from a medical professional. Contact HR Contact Name at Phone Number or Email.
In the past 14 days, have you:
Rows Yes No
Had close contact with a person who shows symptoms of, or has been diagnosed with, COVID-19?
Have you travelled outside of the U.P. in the last 14 days?
Close contact? If “Yes”, please do not enter this work site, or leave the work site and return home. Self-quarantine at home for 14 days. Contact HR Contact Name at Phone Number or Email.

Travel outside of the U.P.? Contact HR Contact Name at Phone Number or Email. You may be excluded from in-person work or you may be required to wear a mask during all in-person for 14 days upon your return.
Source: Executive Orders 2020-110, 2020-97; Barry-Eaton District Health Dept (MI) v.5-15-20; by LKR 6-4-20.
Should be Empty:

Rows	Yes	No
Fever (felt feverish or above 100.4° F)?
New or worsening cough?
Shortness of breath?
Sore throat?
Vomiting, Diarrhea, or Chills?
Muscle Pain?
Sudden loss of taste or smell?

Rows	Yes	No
Had close contact with a person who shows symptoms of, or has been diagnosed with, COVID-19?
Have you travelled outside of the U.P. in the last 14 days?

Organization Name