Title Page

  • Project Name

  • Employee Name

  • Date

  • Temperature Scan Results
  • Health and Safety Officer

  • Location
  • 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.


  • 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?

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

  • 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?

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


  • Health and Safety Officer Signature

  • Employee Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.