Employees Covid-19

Have you, or anyone you have been in close contact with been diagnosed with COVID-19, or been placed on quarantine for possible contact with COVID-19? *

YES

NO

Have you been asked to self-isolate or quarantine by a medical professional or a local public health official? *

YES

NO

Have you experienced any cold or flu-like symptoms in last 14days ( to include fever, cough, sore throat, respiratory illness, difficulty breathing)? *

YES

NO

Date and time *

Have you recently experienced a loss of taste and smell? *

YES

NO

Do you have a fever (temperature over 100.30F) *

YES

NO

First and Last Name: *

Email: *

Comments/Questions:

ACKNOWLEDGEMENT : I acknowledge that if I answer YES to any of the questions above, I MUST STAY HOME and notify my employer *

Yes, I will

Have you experienced any gastrointestinal symptoms such as nausea/ vomiting, diarrhea, loss of appetite? *

YES

NO

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