COVID-19 SCREENING QUESTIONNAIRE

The safety of our employees is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the Coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to entering the worksite. Please do not enter the worksite until your responses have been reviewed and your entry has been approved.

Please respond to each of the following questions truthfully and to the best of your ability. Your
participation is important to help us take precautionary measures to protect you and our other employees.

Name

Phone

Position

Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms?

	Yes	No
Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)
Cough
Shortness of breath or difficulty breathing
Sore throat
New loss of taste or smell
Chills
Head or muscle aches
Nausea, diarrhea, vomiting

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?

Yes

No

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?

Yes

No

Have you been tested for COVID-19 and are waiting to receive test results?

Yes

No

Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms?

Yes

No

In the past 14 days, have you been on a commercial flight or traveled outside of the country?

Yes

No

In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the country?

Yes

No

Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? If “yes”, please provide a brief explanation.

Yes

No

Explanation

Signature

Clear

Date

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential. Any questions should be directed to your manager or your human resources representative.

Access to worksite:

Approved

Denied