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?

NO

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

NO

YES

SUBMIT

CANCEL