Health Check Before Work For Staff

Are you feeling well today? *

Yes

No

Since your last day of work, or last visit here, have YOU had any of these symptoms? *

• Fever or chills
• Cough (not due to allergies)
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose(not due to allergies)
• Nausea or vomiting
• Diarrhea

Yes

No

Since your last day of work or last visit here, has someone in your home or someone you have had close contact with (within 6 feet for more than 10 minutes), exhibited any of these symptoms: *

• Fever or chills
• Cough (not due to allergies)
• Shortness of breath or difficulty breathing
• Fatigue
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose(not due to allergies)
• Nausea or vomiting
• Diarrhea

Yes

No

In the last 30 days, have you, someone in your home, or someone you have had close contact with (within 6 feet for more than 10 minutes) tested positive for COVID-19? *

Yes

No