Return to Work Health Screening Questionnaire
Please complete the Return to Work Health Screening Questionnaire before resuming work after your absence.
Full Name
*
First Name
Last Name
Employee ID
*
Department
*
Contact Email
*
example@example.com
Date of Return
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you experienced any of the following symptoms in the past 14 days? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
None of the above
Have you been in close contact with anyone diagnosed with a contagious illness in the past 14 days?
*
Yes
No
Not sure
Have you traveled internationally or to a high-risk area in the past 14 days?
*
Yes
No
Are you currently awaiting results of a medical test related to a contagious illness?
*
Yes
No
Do you confirm that, to the best of your knowledge, your responses are accurate and you are fit to return to work?
*
Yes, I confirm
No, I am not ready to return
Submit
Should be Empty: