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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. Self-isolate at home and contact your primary care physician’s office for direction. •You should isolate at home for a minimum of 7 days since symptoms first appear. •You must also have 3 days without fevers and improvement in respiratory symptoms.

  3. IN THE PAST 24 HOURS, HAVE YOU EXPERIENCED:

  4. Fever or felt feverish:*

  5. Cough:*

  6. Shortness of breath/difficulty breathing:*

  7. Sore throat:*

  8. Diarrhea:*

  9. Chills*

  10. Muscle Pain*

  11. New loss of taste or smell*

  12. You answered “yes” to one of the symptoms listed and/or or your temperature is 100.4°F or higher. Please do not go to into work. Self-isolate at home and contact your primary care physician’s office for direction. •You should isolate at home for a minimum of 7 days since symptoms first appear. •You must also have 3 days without fevers and improvement in respiratory symptoms.*

  13. IN THE PAST 14 DAYS, HAVE YOU:

  14. If you answer “yes” to either of these questions, please do not go into work. Self-quarantine at home for 14 days.

  15. Had close contact with an individual diagnosed with COVID-19?*

  16. Traveled internationally or taken a cruise?*

  17. 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.*

  18. Leave This Blank: