Title Page

  • Conducted on

  • Prepared by

  • Location

Screening

  • 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?

  • Please ask them to do so

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

  • 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)

  • 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?

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

  • Are you having chills?

  • 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?

  • If YES, ask question #2 below.

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

  • 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.

Completion

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