covid screening

Name *

First Name

Last Name

1. Do you have a fever? *

YES

NO

2. Do you have any of the following signs or symptoms?

New onset of cough

Worsening chronic cough

Sore throat

Shortness of breath

Difficulty breathing

New loss or decrease in sense of taste or smell

Runny nose

Sneezing (not allergy related)

Hoarse voice

Nasal congestion

Chills

Headache

Unexplained fatigue or malaise

Difficulty swallowing

Nausea/vomiting, diarrhea, abdominal pain

3. Have you traveled or had close contact with anyone who has traveled in the past 14 days? *

YES

NO

4. Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19? *

YES (if yes, go to question 5)

NO (if no, screening is complete)

5. Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g. mask, N95, gloves, goggles, etc.) when you had close contact with a suspected or confirmed case of COVID-19?

YES

NO