Rogers Employee Health Screening

Employee

Today’s Date

Date

Time

Hour Minutes

AM/PM Option

Have you had any of the following symptoms?*

Have you been told by a health official to self-quarantine or have you been officially quarantined?*

YesNo

Have you had close contact (within 6 feet for more than 30 minutes) with anyone who has tested positive for COVID-19 while you were not wearing a mask?

YesNo

Temperature Reading

Employee Signature

Clear

Manager/Tester Initials