Restaurant Health Screening Questionnaire
Please complete this health screening form before your shift to help us maintain a safe workplace.
Full Name
*
First Name
Last Name
Employee Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Position/Department
*
Please Select
Kitchen Staff
Wait Staff
Bar Staff
Host/Hostess
Manager
Other
Date of Screening
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently experiencing any of the following symptoms? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath or difficulty breathing
Loss of taste or smell
Sore throat
Muscle or body aches
None of the above
Other
In the past 14 days, have you been in close contact with anyone diagnosed with a contagious illness (e.g., COVID-19, flu)?
*
Yes
No
Not sure
Have you traveled internationally or to a high-risk area in the past 14 days?
*
Yes
No
Have you received a vaccination for seasonal illnesses (e.g., flu) in the past year?
Yes
No
Prefer not to say
Please rate your overall health today.
*
1
2
3
4
5
Is there anything else we should know regarding your current health or recent exposures?
Submit Screening
Should be Empty: