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Employee Wellness Screening

  1. 1. In the last 48 hours have you had any of the following symptoms that are not attributable to another condition? Check all that apply or “C” that none of them apply. *

  2. 2. In the last 48 hours have you had any of the following symptoms that are not attributable to another condition? Check all that apply or “J” if none of them apply. *

  3. 3. Within the last 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection?*

  4. 4. Within the past 14 days, have you been in close contact with anyone that you know that had COVID-19 or COVID-like symptoms? Contact is being 6 feet or closer for more than 15 minutes with a person or having direct contact with fluids from a person with COVID-19 (for example, being coughed or sneezed on).*

  5. 5. Have you had a positive COVID-19 test for active virus in the past 10 days?*

  6. 6. Have you taken your temperature today?*

  7. If yes, was it below 100.4 degrees?*

  8. By submitting this form you certify that you have answered this form truthfully to the best of your ability.

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