• 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

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