Health Screening Questionnaire To mitigate the spread of COVID-19 and reduce the risk of exposure to our employees, we are requiring each employee to complete a health screening questionnaire before their shift every day. Some counties even require employers to conduct these screenings. Any employee who refuses to provide answers to these questions will not be permitted to work and may be sent home without pay. Depending on answers to the questionnaire, an employee may be sent home and instructed to contact their healthcare provider for further instructions. Employees who are unable to work because of answers given on this questionnaire, may be eligible for paid leave and, if needed, enhanced unemployment benefits, until they are safely able to return to work.Employee Name* First Last Date* MM slash DD slash YYYY Supervisor Administering Questionnaire* First Last Self-Declaration by Employee1. Have you been diagnosed with COVID-19 or has a healthcare professional recommended that you be quarantined or self-isolate?* Yes No 2. Are you experiencing, or have you experienced in the past 14 days, any of the following symptoms:*• Fever above 100.4 degrees • Cough • Sore throat • Respiratory illness • Difficulty breathing • Feeling cold, clammy, light-headed, or too weak to stand • Dry cough and/or coughing up blood Yes No If yes, please describe:3. In the last 14 days, have you had close contact with or cared for someone diagnosed with COVID-19 or been told by a healthcare provider to quarantine?* Yes No 4. In the last 14 days, have you had close contact with or cared for anyone who has experienced any of the symptoms mentioned in #2 above?* Yes No Approval to Work:* Granted Denied Reason for denial:Employee temperature if taken at work:Please enter a number from 85.0 to 115.0.
