COVID-19: Employee Temperature Checklist

• Location

  Jasper’s Uptown

  Jasper’s Richardson

  Jasper’s Woodlands

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

  Yes

  No

• Please wash and/or sanitze your hands.

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

  Select Fever New or worsening cough New or worsening shortness of breath None of the above

  • Fever
  • New or worsening cough
  • New or worsening shortness of breath
  • None of the above

• If NO to all, proceed to remaining questions

3. Please input your temperature:

• If you do not have a thermometer to take their temperature, contact your manager.

• 3A. Do you have a fever (temperature 100.4°F or greater)

  No

  Yes

• If YES, Please contact your manager immediately and do not enter the building.

  Select Please contact your manager immediately and do not enter the building.

  • Please contact your manager immediately and do not enter the building.

• If NO, proceed to question #3C.

• Are you feeling feverish?

  No

  Yes

• If YES to any, Please contact your manager immediately and do not enter the building.

  Safe

  At Risk

• 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.

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

  No

  Yes

• If YES, proceed to the next question.

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

  No

  Yes

• If YES to any, Please contact your manager immediately and do not enter the building.

• If NO, proceed to step #4.

• If NO, proceed to step #4.

• 4. You can now enter the building, please keep record your entry upon arrival.

• IMPORTANT:Wash your hands or use alcohol-based hand sanitizer throughout your entire time in the building.

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

Completion

• Comments

  Date

• Signature

  Sign