Employee Health Screening Questionnaire
Please complete the following health screening questions to ensure a safe work environment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you currently have any of the following symptoms? (Check all that apply)
Have you had close contact with anyone diagnosed with a contagious illness in the past 14 days?
*
Yes
No
Prefer not to say
Have you traveled internationally or to high-risk areas recently?
Yes
No
Have you experienced any of the following in the past 24 hours?
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
Sore throat
None of the above
Describe any other health concerns or symptoms not listed above.
Consent to health screening and data collection for workplace safety purposes.
*
1
I agree
Signature
*
Submit
Submit
Should be Empty: