Covid-19 Hazard Assessment Checklist
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Name
First Name
Last Name
Age
Gender
Male
Female
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
COVID-19 Symptoms
Fever
Nasal congestion
Runny nose
Loss of taste
Loss of smell
Difficulty of breathing
Cough
Sore throat
Headache
Body weakness
Diarrhea
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Hazard Checklist
Rows
Yes
No
Are you experiencing any COVID-19 symptoms? (Please refer to information above)
1
2
Are you living with someone who has COVID-19 symptoms?
3
4
Have you travelled outside the state or country within the last 14 days?
5
6
Have you been in contact with someone who has COVID-19 symptoms?
7
8
Do you consider yourself fit to work during this pandemic?
9
10
Have you been vaccinated for COVID-19?
11
12
Employee Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: