Workplace Entry Screening Form

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

Name

First NameLast Name

Email

example@example.com

Are you experiencing shortness of breath?

YesNo

Do you have a fever, or do you feel feverish?

YesNo

Do you have a cough, sore throat, runny nose, nausea, or diarrhea?

YesNo

Do you have any loss of taste and/or smell?

YesNo

Have you been around anyone exhibiting these symptoms within the past 10 days?

YesNo

Are you living with anyone who is sick or quarantined?

YesNo

Additional Notes?

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!