COVID-19 Daily Screening

This form is to be completed each day before you report to work. When you submit, it will be sent to your supervisor.

If you see this don't fill out this input box.

Employee email

Supervisor Name

*Supervisor Email

*New or worsening cough?

YesNo

*Shortness of breath

YesNo

*Chills

YesNo

*Repeated shaking with chills?

YesNo

*Muscle Pain

YesNo

*Headache?

YesNo

*Sore Throat?

YesNo

*Loss of taste or smell?

YesNo

*Diarrhea?

YesNo

*Feeling feverish or temperature at or above 100 F

YesNo

*Have you been in contact with anyone who has confirmed case of COVID-19?

YesNo

If you answered "Yes" to any of the questions above, do NOT come to work. Contact your supervisor immediately.

If you answered "No" to all of the questions above, you are cleared to come to work.

Health

Daily COVID Health Screening

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Health

Daily COVID Health Screening

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