Employee's Name

Employee's Phone number

Person/Department

Have you traveled outside of the country or been in close contact with anyone who has traveled outside of the country within the last 14 days? Have you traveled outside of the country or been in close contact with anyone who has traveled outside of the country within the last 14 days? Yes No

Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? Yes No

Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem? Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, shortness of breath or other respiratory problem? Yes No

Have you had any of the following symptoms since your last day at work or the last time you were here that you cannot attribute to another health condition? Have you had any of the following symptoms since your last day at work or the last time you were here that you cannot attribute to another health condition? Fever or feeling feverish? Chills? A new cough? Shortness of breath? A sore throat? New muscle aches? New headache? New loss of smell or taste?