Kansas Reopening: Employee Health Screening Form

• Company Name

• Conducted on

  Date

• Prepared by

• Location
  Address

• Please complete this form before you start your shift and after you complete each shift.
  
  ● If you answer “Yes” to a combination of two of any of the following, please notify your supervisor and leave immediately: Fever, cough, shortness of breath, chills, runny nose, head/body aches, sore throat, nausea/vomiting, sudden loss of taste or smell, diarrhea.
  
  ● Temperature: 100.4 is automatic “No GO.”
  If temperature is 99.2 or higher, but less than 100: begin monitoring your temperature twice a day for a minimum of 7 days to determine if your temperature is going up or down. You should notify your supervisor.

BEFORE STARTING SHIFT

• Fever

  ✔

  ✖

  N/A

• Cough

  ✔

  ✖

  N/A

• Shortness

  ✔

  ✖

  N/A

• of breath

  ✔

  ✖

  N/A

• Chills

  ✔

  ✖

  N/A

• Runny Nose

  ✔

  ✖

  N/A

• Head/ body

  ✔

  ✖

  N/A

• aches

  ✔

  ✖

  N/A

• Sore throat

  ✔

  ✖

  N/A

• Nausea,

  ✔

  ✖

  N/A

• vomiting

  ✔

  ✖

  N/A

• Sudden loss of

  ✔

  ✖

  N/A

• taste or smell

  ✔

  ✖

  N/A

• Diarrhea

  ✔

  ✖

  N/A

• OTHER SYMPTOMS

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• Name and Signature

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