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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. If you have checked at least “A” or “B” please stay home and notify your supervisor.*

  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 “H” if none of them apply. If you have checked two or more of the symptoms, please stay home and notify your supervisor.*

  3. 3. Are you ill or caring for someone who is ill with symptoms related to COVID-19, if so, stay home and notify your supervisor?*

  4. 4. In the last two weeks did you care of have close contact with someone diagnosed with COVID-19, if so, stay home and notify your supervisor?*

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

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

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

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