Veterinary Staff Health Evaluation Form
Complete this form to assess your current health status before or during your work shift.
Full Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you currently have any of the following symptoms? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath
Sore throat
Fatigue
None of the above
Other
Have you had close contact with anyone diagnosed with a contagious illness in the past 14 days?
*
Yes
No
Not sure
Are you up to date on required workplace immunizations (e.g., rabies, tetanus)?
*
Yes
No
Not sure
Have you traveled outside your local area in the past 14 days?
*
Yes
No
How would you rate your current overall physical health?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How would you rate your current mental well-being?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Are you fit to safely perform your duties today?
*
Yes
No
Unsure
Additional comments or concerns (optional)
Submit Evaluation
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