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COVID-19 Health Screening

  1. Coronavirus Disease (COVID-19) Workplace Health Screening.
    Please complete this brief health screening questionnaire before coming into the workplace.
  2. If you answer “yes” to any of the symptoms listed below, or your temperature is 100.4°F or higher, please do not go to into work. Inform your supervisor and self-isolate at home. You must consult with the health department and they will need to provide clearance for your return to work. •You should isolate at home for a minimum of 10 days since symptoms first appear; and • 24 hours have passed since the resolution of fever without the use of fever-reducing medications; AND •other symptoms have improved.
  3. IN THE PAST 24 HOURS, HAVE YOU EXPERIENCED:
  4. Fever or Chills:*
  5. Cough:*
  6. Shortness of breath/difficulty breathing:*
  7. Fatigue:*
  8. Muscle or body aches:*
  9. Headache:*
  10. New loss of taste or smell:*
  11. Sore throat:*
  12. Congestion or runny nose:*
  13. Nausea or vomiting:*
  14. Diarrhea:*
  15. You answered “yes” to one of the symptoms listed and/or or your temperature is 100.4°F or higher. *
    Please do not go into work. Inform your Supervisor and self-isolate at home. You must consult with the health department and they will need to provide clearance for your return to work.
    •You should isolate at home for a minimum of 10 days since symptoms first appear; AND .
    •24 days have passed since the resolution of fever without the use of fever-reducing medications; AND
    •other symptoms have improved.
  16. IN THE PAST 14 DAYS, HAVE YOU:
  17. If you answer “yes” to either of these questions, please do not go into work. Self-quarantine at home for 14 days.
  18. Had close contact with an individual diagnosed with COVID-19?*
  19. Traveled internationally or taken a cruise?*
  20. You answered “yes” to one or both of the travel related questions. Please do not go into work. Self-quarantine at home for 14 days.*
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