Please enable JavaScript in your browser to complete this form.Name *FirstLastDate / Time *DateTimeInstructionsALL employees and volunteers working with Guests must be asked the following below. This record will be kept for 14 days from completion of this form and this form is available upon request from the Public Health Department.1 - Have you washed your hands or used alcohol-based hand sanitizer on entry? *YesNo - Please do so now2 - Do you have any of the following respiratory symptoms which are new or unusual for you? *FeverNew or worsening coughNew or worsening shortness of breathNone of the aboveIf YES to any, restrict them from entering the building and send person home.* If NO to all, proceed to remaining questions3 - Employee's Temperature *3A - Do you have a fever (temperature 100.4°F or greater) *YesNoIf YES , restrict them from entering the building and send the person home. If NO, proceed to question #3B.3B - 1 - Are you feeling feverish? *YesNo3B - 2 - Are you having chills? *YesNoIf YES to any, restrict them from entering the building and send person home.* If NO, proceed to question 3C.3C - Have you been exposed to any persons with confirmed COVID-19 by lab test? *YesNoIf YES , contact your supervisor immediately** If NO, proceed to #44 - You may enter building - please remember to: *Wash your hands or use alcohol-based hand sanitizer throughout your time in the buildingNot shake hands with, touch, or hug others during your time in the buildingPerson performing screening **The person being sent home, must inform their supervisor and Human Resources that they were sent home and is responsible for following-up with their primary care physician if needed. **Supervisors review COVID-19 policy for employees who have symptomsNameSubmit
