Employee Health Screenings

1) Employee Name

2) Date

3) Time In

4) In the past 24 hours, have you experienced: Subjective fever

5) New or worsening cough

6) Shortness of breath

7) Sore throat

8) Diarrhea

9) Current Temperature

10) In the past 14 days, have you had close contact with an individual diagnosed with COVID-19?

11) Travelled via airplane internationally or domestically?

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