Covid Employee Screening Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Department
Body Temperature
Any of the following symptoms?
Cough
Shortness of breath
Sore throat
Fever
Headache
Loss of smell or taste
Having chills
Muscle pain or body aches
Vomiting
Fatigue
Diarrhea
Are these symptoms present?
Yes
No
Employee should visit a healthcare facility immediately!
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Screened by
First Name
Last Name
Submit
Should be Empty: