COVID 19 Employee Screening Questionnaire

• Project Name

• Employee Name

• Date

  Date
Temperature Scan Results

• Health and Safety Officer

• Location
  Address

• If an employee answers “Yes” to any of the screening questions, immediately activate your company’s emergency protocol. The screener should:
  
  • Ensure the screening results are accurate.
  • Ask the employee to go home and call their primary care physician.
  • Notify management.

EMPLOYEE SCREENING QUESTIONNIARE

• 1. Have you or someone in your household or workplace been in close contact with a person who has signs of or has COVID-19?

  Yes

  No

  N/A

• 2. Have you been medically directed to self-quarantine?

  Yes

  No

  N/A

• 3. In the last 72 hours, have you had: a new fever of 100.4°F, a new cough, shortness of breath, sore throat, new muscle aches or a loss of taste or smell?

  Yes

  No

  N/A

• 4. Do you have a clean face mask and other proper PPE?

  Yes

  No

  N/A

SIGN OFF

• Health and Safety Officer Signature

  Sign

• Employee Signature

  Sign