Symptom Screening Form

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Daily Symptom Screening

Please complete all information for any unusual symptom onset, positive test for COVID or exposure to someone who has tested positive for COVID

First Name

Last Name

Position and City

Please check any symptoms noticed today

Temperature of 100.4 degrees F or higher

Shortness of breath or difficulty breathing

Cough

Chills

Muscle pains

Tiredness

New loss of taste or smell

Headache

Nausea or vomitting

Diarrhea

Sore throat

Congestion or runny nose

None of the above

Date of Symptom Onset

COVID Test Date

COVID Test Result

Positive

Negative

No Test

(STAFF EXPOSURE IF COVID POSITIVE) dating back 48 hours prior to symptom onset date, have you been within 6 feet of a co-worker for 15 minutes or more over a 24-hour period?

Yes

No

Thank you for submitting!

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