• Workplace Entry Screening Form

  • Please answer the following questions before entering the workplace for each working day.

  • Are you experiencing shortness of breath?
  • Do you have a fever, or do you feel feverish?
  • Do you have a cough, sore throat, runny nose, nausea, or diarrhea?
  • Do you have any loss of taste and/or smell?
  • Have you been around anyone exhibiting these symptoms within the past 10 days?
  • Are you living with anyone who is sick or quarantined?

  • DO NOT GO TO THE WORKPLACE TODAY.

    Please notify your supervisor that you will be staying home and contact Human Resources via HR@example.com or 111-111-1111.

  • You may go to work today!

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