COVID-19: Employee Temperature Checklist

• Conducted on

  Date

• Prepared by

• Location
  Address

• This checklist is derived from https://www.tuolumnecounty.ca.gov/DocumentCenter/View/14186/COVID-19-Employee-Screening-Form

• If a person is being sent home, they must inform their supervisor and/or Human Resources that they were sent home and is responsible for following-up with their primary care physician if needed.

• 1. Have you washed your hands or used alcohol-based hand sanitizer on entry?

  Yes

  No

• Please ask them to do so

• 2. Do you have any of the following respiratory symptoms?

  Select Fever New or worsening cough New or worsening shortness of breath

  • Fever
  • New or worsening cough
  • New or worsening shortness of breath

• If YES to any, restrict them from entering the building and send person home.

• If NO to all, proceed to remaining questions

3. Employee’s temperature:

• If you do not have a thermometer to take their temperature, go to step #3B.

• 3A. Does the employee have a fever (temperature 100.4°F or greater)

  No

  Yes

• If YES, restrict them from entering the building and send person home.

• If NO, proceed to question #3C.

• 3B. Ask the employee the following:

• Are you feeling feverish?

  No

  Yes

• If YES to any, restrict them from entering the building and send person home.

• Are you having chills?

  No

  Yes

• If YES to any, restrict them from entering the building and send person home.

• If NO, proceed to question 3C.

• 3C. Ask the employee the following:

• 1. Have you worked in facilities with confirmed COVID-19 cases?

  No

  Yes

• If YES, ask question #2 below.

• 2. Have you worked with persons with confirmed COVID-19 by lab test?

  No

  Yes

• If YES to any, restrict them from entering the building and send person home.

• If NO, proceed to step #4.

• If NO, proceed to step #4.

• 4. Allow entry to building and remind individual to:

• Wash their hands or use alcohol-based hand sanitizer throughout their time in the building.

• Not to shake hands with, touch, or hug others during their time in the building.

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