Employee Health Log Report Form
Please complete this form to log your current general wellness and workplace attendance-related health information.
Employee Initials or Non-Sensitive ID
*
Reporting Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Shift or Workday
*
Please Select
Morning
Afternoon
Evening
Night
Full Day
Other
Current General Wellness Status
*
Feeling Well
Mild Discomfort
Unwell
Are you experiencing any symptoms today?
*
No symptoms
Yes, mild symptoms
Yes, moderate/severe symptoms
If yes, please specify symptoms (select all that apply):
Cough
Sore throat
Muscle aches
Runny nose
Mild feverish feeling
Other
Current Temperature (°F or °C, if measured)
Any recent exposure, travel, or workplace risk to note?
*
No known exposure or risk
Recent close contact with unwell person
Recent travel
Other workplace risk
Based on your current status, are you fit to work today or is follow-up needed?
*
Fit to work
Needs follow-up
Unsure
Additional Comments (optional)
Submit Health Log
Should be Empty: