COVID-19 Health Screen Coronavirus Disease (COVID-19) Workplace Health Screening Company Name * Employee Name * Date * In the past 24 hours, have you experienced: Subjective fever (felt feverish) * Yes No New or worsening cough * Yes No Shortness of breath * Yes No Sore throat * Yes No Diarrhea * Yes No Current temperature (if known): If you answer “yes” to any of the symptoms listed above, or your temperature is 100.4°F or higher, please do not go to into work. Self-isolate at home and contact your primary care physician’s office for direction. • You should isolate at home for a minimum of 7 days since symptoms first appear. • You must also have 3 days without fevers and improvement in respiratory symptoms. In the past 14 days, have you: Had close contact with an individual diagnosed with COVID-19? * Yes No Traveled via airplane internationally or domestically? * Yes No If you answer “yes” to either of these questions, please do not go into work. Self-quarantine at home for 14 days If you are human, leave this field blank. Submit
