Employee COVID-19 screening questionnaire

You have not experienced any of the following symptoms now or in the last 14 days: Fever (100.4° F/37.8° C or greater as measured by an oral thermometer) Cough, Shortness of breath or difficulty breathing, Sore throat, New loss of taste or smell, Chills, Head or muscle aches, Nausea, diarrhea, vomiting.

• Yes
• No

In the past 14 days, you have not been in direct contact with anyone who has experienced any of the above symptoms or have experienced any of the above symptoms since your contact? the above symptoms or have experienced any of the above symptoms since your contact?

• Yes
• No

In the past 14 days, you have not been in the immediate vicinity of anyone who tested positive for COVID-19?

• Yes
• No

You have not been tested positive for COVID-19 or presumably positive for COVID-19 based on your healthcare provider's assessment or your symptoms? based on your healthcare provider's assessment or your symptoms?

• Yes
• No

In the past 14 days, you have not been on a commercial flight or travelled outside of the United States?

• Yes
• No

In the past 14 days, you have not been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?

• Yes
• No

You have no reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? If “No”, please provide a brief explanation.

• Yes
• No