Employee COVID-19 Screening Questionnaire (Demo)

The safety of our employees is our overriding priority. 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 respond to each of the following questions truthfully and to the best of your ability.

Full Name Employee ID

Are you currently experiencing, or have your experienced in the past 14 days - fever (100.4F / 37.8 C) or greater as measured by a thermometer)? Yes No

Are you currently experiencing (or experienced within the last 14 days) -cough, difficulty breathing, sore throat, loss of taste or smell, chills or muscle aches, nausea, diarrhea or vomiting? Yes No

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 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

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? Yes No

If you answered yes, please give a brief explanation