COVID-19 Staff Screen

Date *

First Name *

Last Name *

Contact Number *

Have you been diagnosed with COVID-19? *

YesNo

Have you come into contact with a person who has a confirmed or suspected case of COVID-19 within the past 14 days? *

YesNo

Are you experiencing any of the following? *

Fever or chillsAcute respiratory infection including cough, sore throat, shortness of breath, runny nose, loss of smell or loss of tasteNew onset of other symptoms which could be consistent with COVID-19 including headache, muscle aches, stuffy nose, nausea, vomiting or diarrheaNone of the above

If you have answered YES to any of the above 3 questions:

DO NOT proceed to work or have contact with any other employees.
Remain at home or in your vehicle.
Contact your manager immediately.

Signature *

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