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COVID-19 Employee Daily Check List
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COVID-19 Employee Daily Check List
COVID-19 Employee Daily Check List
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2021-01-27T16:51:45-05:00
COVID Employee Checklist
COVID compliance questionnaire for contact tracing purposes
First Name
*
Last Name
*
Date
*
MM slash DD slash YYYY
Do you have any of the following?:
*
Fever
Shortness of Breath (not severe)
Cough
Chills
Repeated shaking with chills
Muscle Pain
Headache
Sore Throat
New loss of taste or smell
Have contact with someone diagnosed with COVID-19?
Have you tested positive for COVID-19 in the past 14 days?
Have you traveled out of state in the last 14 days?
I am working from home today (prior approval required).
I have none of the symptoms listed above.
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