Hospitality Staff Health Assessment Form
Please complete this health screening before or during your work shift to ensure fitness for duty.
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift
*
Please Select
Morning
Afternoon
Evening
Night
Are you experiencing any of the following symptoms? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath
Sore throat
Loss of taste or smell
None of the above
Have you had close contact with anyone diagnosed with a contagious illness in the past 7 days?
*
Yes
No
Unsure
What is your current temperature range?
*
Below 37°C (98.6°F)
37°C - 37.9°C (98.6°F - 100.2°F)
38°C (100.4°F) or above
Not measured
How would you rate your overall fitness for duty today?
*
1
2
3
4
5
Are you able to perform your assigned duties safely and effectively today?
*
Yes
No
With limitations
Wellness Checklist
*
Rows
Today
Past 7 Days
No symptoms present
1
2
Felt unwell
3
4
Required medication
5
6
Missed work
7
8
I confirm that the information provided is accurate to the best of my knowledge.
*
I confirm
Submit Assessment
Should be Empty: