Title Page

  • Company Name

  • Conducted on

  • Prepared by

  • Location
  • 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

  • Cough

  • Shortness

  • of breath

  • Chills

  • Runny Nose

  • Head/ body

  • aches

  • Sore throat

  • Nausea,

  • vomiting

  • Sudden loss of

  • taste or smell

  • Diarrhea

  • OTHER SYMPTOMS

SIGN OFF

  • Name and Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.