Prevent COVID-­19

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Yes

  No

  N/A

• Date:

  Date

Screening Questions

• First Name

• Last Name

• Check

  Yes

  No

  N/A

• Temperature

• Cough

  Yes

  No

  N/A

• Circle either

  Y

  N

Sore Throat

• Circle either

  Yes

  No

  N/A

• New Shortness of Breath

  Yes

  No

  N/A

• Circle either

  Y

  N

• Asked to Go home

  Yes

  No

  N/A

• (If Yes to ANY)?

  Yes

  No

  N/A