Employee COVID-19 Self Screening Questionnaire

Employee COVID-19 Self Screening Questionnaire
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
Cough
Shortness of breath of difficulty breathing
OR at least TWO 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
If you answered “Yes” to question one, please DO NOT come into work. You should:
- Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)
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 any part of question two, please DO NOT come into work. You should self quarantine for at least 14 days.
I certify to the best of my knowledge; this information is accurate.
Signature*
Clear
Name*
First NameLast Name
Date*
MonthDayYear
Date
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

	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

	Yes	No
Cough
Shortness of breath of difficulty breathing