Covid Employee Screening Form

Covid Employee Screening Form
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Department
Body Temperature
Any of the following symptoms?
CoughShortness of breathSore throatFeverHeadacheLoss of smell or tasteHaving chillsMuscle pain or body achesVomitingFatigueDiarrhea
Are these symptoms present?
YesNo
Employee should visit a healthcare facility immediately!
Date
MonthDayYear
Date
Screened by
First NameLast Name
Should be Empty: