Covid-19 Mandatory Daily Health Screening Questionnaire
Employee Name
First Name
Last Name
Employee Number
Department
Have you been in close contact with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19 in the past 14 days ?
Yes
No
Have you tested positive for COVID-19 in the past 14 days?
Yes
No
Have you experienced a fever of 100.4 degrees Fahrenheit or greater, a new cough, new loss of taste or smell, or shortness of breath within the past 7 days?
Yes
No
Have you traveled to any states or another country in the past 7 days?
Yes
No
I, the employee undersigned, agree with the following statements:
If my test become positive for COVID-19, I will notify Human Resources immediately.
I understand that I am required to immediately disclose to my supervisor or Human Resources if and when my responses to any of the aforementioned questions change, including during or outside work hours.
I confirm that the information given in this form is true, complete and accurate.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: