COVID-19 Shift Screening Form

Do you have any of the following symptoms?

Rows	Yes	No
Fever
Chills
Conjunctivitis (pink eye)
Cough
Difficulty breathing / Shortness of breath (at rest or laying down)
Sore throat
Fatigue
Gastrointestinal symptoms (nausea, vomiting, diarrhea, loss of appetite)
Headache
Muscle or joint pains
Runny nose / Nasal congestion
Unexplained loss of sense of smell or taste

Have you had close contact with a person who was found to have acute respiratory illness within 14 days?
Have you had close contact with a person with a confirmed or probable case of COVID-19 infection within 14 days?
Have you been tested for COVID-19 infection in the past 14 days?
I hereby declare that the information provided above are true and correct to the best of my knowledge.
Signature of Employee
Clear
Date Signed
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Select theme: