Novel Coronavirus (COVID-19) Entry Screening

(COVID-19) ENTRY SCREEENING FORM
EFC/FORM/HR/001 / EFFECTIVE 12/29/2020 / REVISION # 0
NAME OF COMPANY: ELIZABETH'S FOOD CO.
SCREENING LOCATION: FRONT LOBBY
SCREENING CONDUCTED BY    First Name   Last Name
DATE:      TIME:
EMPLOYEE/CONTRACTOR/VISITOR NAME:   First Name   Last Name
You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT come enter the company’s buildings.
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:*
Yes No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell
Cough
Shortness of breath of difficulty breathing
2) In the last 14 days have you:*
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 questions 1 or 2, please DO NOT come into work or plant for visit/appointment
Negative Screen (Cleared). If the individual has no symptoms and no contact to a known or suspected COVID-19 case in the last 14 days they can be cleared to enter the facility.
• Positive Screen (Not Cleared).
- If the individual has had contact to a known or suspected COVID-19 case in the last 14 days they should be sent home immediately and asked to quarantine at home. Provide them with the quarantine instructions found at ph.lacounty.gov/covidquarantine.
- If the individual is showing any of the symptoms noted above they should be sent home immediately and asked to isolate at home. Provide them with the isolation instructions found at ph.lacounty.gov/covidisolation.
Check One:
SCREENING CONDUCTED BY
First Name   Last Name   PAYROLL TITLE Title
DATE:      TIME:
Signature*
Clear
Should be Empty:

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

	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

(COVID-19) ENTRY SCREEENING FORM