2021 Staff Health Screening Form

CONTACT HISTORY FIRST NAME Yes No Fever (above 100.4 F) Cough Shortness of breath New loss of taste or smell Body aches Diarrhea Lice Vomiting Itchy / Red eyes Headache Sore throat No symptoms NOTES STAFF NAME: SYMPTOMS IN THE LAST TWO WEEKS - Check all that apply: STAFF HEALTH SCREENING LAST NAME Have you been diagnosed with COVID-19 in the last 90 days? If yes, date of positive test result: ________________ Have you been in contact with someone who tested positive for COVID-19 in the past 14 days? Do you have evidence of COVID-19 antibodies? Have you been fully vaccinated for COVID-19? F TEMPERATURE AT CHECK IN: F Yes No Have you been diagnosed with COVID-19 in the last 90 days? If yes, date of positive test result: ________________ Have you been in contact with someone who tested positive for COVID-19 in the past 14 days? Do you have evidence of COVID-19 antibodies? Have you been fully vaccinated for COVID-19? Fever (above 100.4 F) Cough Shortness of breath New loss of taste or smell Body aches Diarrhea Lice Vomiting Itchy / Red eyes Headache Sore throat No symptoms LAST NAME STAFF HEALTH SCREENING NOTES TEMPERATURE AT CHECK IN: FIRST NAME CONTACT HISTORY SYMPTOMS IN THE LAST TWO WEEKS - Check all that apply: STAFF NAME: