Employee COVID-19 Health Monitoring Log
Complete this daily log to help ensure workplace safety and monitor employee health. Please answer all questions accurately.
Employee Full Name
*
First Name
Last Name
Date of Screening
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Temperature (°F)
*
Are you experiencing any of the following symptoms? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
None of the above
In the past 14 days, have you had close contact with anyone diagnosed with COVID-19?
*
Yes
No
In the past 14 days, have you traveled internationally or to a COVID-19 high-risk area?
*
Yes
No
Are you currently awaiting COVID-19 test results?
*
Yes
No
Have you read and understood the workplace safety protocols for COVID-19?
*
Yes
No
Additional comments (optional)
Submit
Should be Empty: