Office Employee Safety Check-in Form
Please complete this form to check in for your workday and help ensure a safe office environment.
Full Name
*
First Name
Last Name
Employee ID
*
Department
*
Please Select
Human Resources
Finance
IT
Operations
Sales
Marketing
Other
Date of Check-in
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you working onsite or remotely today?
*
Onsite
Remote
Have you experienced any of the following symptoms in the past 24 hours? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
Sore throat
None of the above
Have you had close contact with anyone diagnosed with a contagious illness in the past 14 days?
*
Yes
No
Not sure
Have you traveled internationally in the past 14 days?
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Check In
Should be Empty: