COVID-19 Employee Health Screening

Name *

First

Last

Date / Time *

Date

Time

Instructions

ALL 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? *

Yes
No - Please do so now

2 - Do you have any of the following respiratory symptoms which are new or unusual for you? *

Fever
New or worsening cough
New or worsening shortness of breath
None of the above

If YES to any, restrict them from entering the building and send person home.* If NO to all, proceed to remaining questions

3 - Employee's Temperature *

3A - Do you have a fever (temperature 100.4°F or greater) *

Yes
No

If YES , restrict them from entering the building and send the person home. If NO, proceed to question #3B.

3B - 1 - Are you feeling feverish? *

Yes
No

3B - 2 - Are you having chills? *

Yes
No

If 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? *

Yes
No

If YES , contact your supervisor immediately** If NO, proceed to #4

4 - You may enter building - please remember to: *

Wash your hands or use alcohol-based hand sanitizer throughout your time in the building
Not shake hands with, touch, or hug others during your time in the building

Person 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 symptoms