Employees’ COVID-19 Questionnaire

1. Have you come into close contact (within 6 feet) with someone who has laboratory confirmed COVID-19 diagnosis or with someone who has COVID-19 symptoms in the past 14 days?

YES

2. Have you experienced any of the following symptoms in the past 48 hours?

• Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)
• Cough
• Shortness of breath or difficult breathing
• Muscle or body aches
• Headache
• New loss of taste or smell
• Sore throat
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea

YES

CANCEL