Covid-19 Antigen Testing Form

Type a question

	Yes	No
Have you traveled to any CDC listed COVID-19 hotspots both foreign and domestic locations by either ground or air travel?	1	2
Have you, or anyone in your residence, come in close contact (within 6 feet) with someone who has a suspected or confirmed COVID-19 diagnosis in the past 14 days?	3	4
Are you currently experiencing OR have experienced int he apst 14 days fever (greater than 100.4 F or 38.0 C) OR symptoms of lower respiratory illness such as cough, shortness of breath, or difficulty breathing?	5	6
Temperature Screening done?	7	8
Have you been asked to self-isolate or quarantine by your doctor or public health official?	9	10

Results of Temperature Screening:
NOTE: If an employee, visitor or vendor answer 'Yes' to any of the above questions, they will be asked to leave the workplace or jobsite immediately and seek medical evaluation. Re-admittance will be allowed only with adequate medical documentation.
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