Employee COVID-19 Screening Questions

Within 2 hours of starting your shift, certify, to the best of your knowledge:

Have you had any symptoms associated with Covid in the past 14 days: fever, chills, cough, sore throat, loss of sense of taste, muscle pain, shortness of breath or difficulty breathing?*
- Yes
- No
Has anyone in your household has had any of these symptoms or been determined to have COVID in the past 14 days?*
- Yes
- No
Have you been in close contact with anyone who has COVID or COVID symptoms in the past 14 days?*
- Yes
- No
Have you maintained the social distancing guidelines promulgated by the CDC for at least the last 14 days when outside your household – six-foot distancing, wearing a mask, and regular hand washing?*
- Yes
- No
Please enter your name to confirm the above answers are true*