COVID-19 Employee Pre-Shift Screening Questionnaire

COVID-19 Employee Pre-Shift Screening Questionnaire
This questionnaire aims to identify employee who may potentially infected by coronavirus prior to work shifts in order to minimize the spread of the virus. Please be as accurate as possible while answering all the questions considering safety of you, your colleagues and families.
Name
First NameLast Name
Employee ID
Have you, or anyone in your household, go abroad in the last 14 days?
Within the past 14 days, have you had contact with anyone that you know had COVID-19 or COVID-like symptoms?
Have you experienced any of the following symptoms in the last 14 days:
Rows Yes No
Fever 1 2
Dry Cough 3 4
Tiredness 5 6
Aches and Pains 7 8
Sore Throat 9 10
Diarrhea 11 12
Conjunctivitis 13 14
Headache 15 16
Loss of Taste or Smell 17 18
A Rash on Skin, or Discolouration of Fingers or Toes 19 20
Should be Empty:

Rows	Yes	No
Fever	1	2
Dry Cough	3	4
Tiredness	5	6
Aches and Pains	7	8
Sore Throat	9	10
Diarrhea	11	12
Conjunctivitis	13	14
Headache	15	16
Loss of Taste or Smell	17	18
A Rash on Skin, or Discolouration of Fingers or Toes	19	20

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