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 Name
Last Name
Employee ID
Have you, or anyone in your household, go abroad in the last 14 days?
Yes
No
Within the past 14 days, have you had contact with anyone that you know had COVID-19 or COVID-like symptoms?
Yes
No
Have you experienced any of the following symptoms in the last 14 days:
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
Submit
Should be Empty: