Employee Temperature Check Survey Form
Complete the Employee Temperature Check Survey Form to record your daily screening. Please answer all questions accurately.
Full Name
*
First Name
Last Name
Department
*
Please Select
Human Resources
Operations
Sales
Marketing
IT
Other
Date of Screening
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Screening
*
Hour Minutes
AM
PM
AM/PM Option
Current Body Temperature (°F)
*
Are you experiencing any of the following symptoms?
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
None of the above
Have you had close contact with anyone diagnosed with a contagious illness in the past 14 days?
*
Yes
No
Have you traveled outside your local area in the past 14 days?
*
Yes
No
How would you rate your overall health today?
*
1
2
3
4
5
Additional Comments (optional)
Submit Check-In
Should be Empty: