Temporary Candidate COVID-19 Self Screening

Temporary Candidate COVID-19 Self Screening
Must be completed each morning prior to accepting any available temporary assignments.
You must answer “NO” to all the questions in this questionnaire in order to enter dental practice physical location. If you answer “YES” to any of the questions, please DO NOT proceed with your temporary assignment.
If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps AND notify your manager and HR.
1) Have you had any of the following symptoms in the last 24 hours?
Rows Yes No
Cough
Shortness of breath of difficulty breathing
OR at least TWO of the following symptoms in the last 24 hours:
Rows Yes No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell
If you answered “Yes” to question one, please DO NOT come into work. You should:
- Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)
2) In the last 14 days have you:
Rows Yes No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise
If you answered “Yes” to any part of question two, please DO NOT come into work. You should self quarantine for at least 14 days.
I certify to the best of my knowledge; this information is accurate.
Signature
Clear
Name
First NameLast Name
Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Rows	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

Rows	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

Rows	Yes	No
Cough
Shortness of breath of difficulty breathing