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Sample COVID-19 Screening Form for Employers

This document is a sample COVID-19 screening form for employers to assess employee health before entering the workplace. It includes questions regarding recent travel, contact with COVID-19 positive individuals, symptoms, and temperature checks. Based on the responses, employees are categorized as either passing or failing the screening, with instructions for self-isolation if necessary.

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varma.rameshb
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15 views

Sample COVID-19 Screening Form for Employers

This document is a sample COVID-19 screening form for employers to assess employee health before entering the workplace. It includes questions regarding recent travel, contact with COVID-19 positive individuals, symptoms, and temperature checks. Based on the responses, employees are categorized as either passing or failing the screening, with instructions for self-isolation if necessary.

Uploaded by

varma.rameshb
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Sample COVID-19 Screening Form for

Employers

Name of Employee: Date:

1. Have you traveled outside of Country in the last 14 days (circle answer)? YES or NO

2. Has someone you are in close contact with tested positive for COVID-19
in the last 14 days? YES or NO

3. Are you in close contact with a person who is sick with new respiratory
symptoms or who recently traveled outside of the country? YES or NO

4. Do you have a fever? (temperature ≥ 37.8 °C) YES or NO


Tº (Screener will have employee take temperature)

5. Do you have any of these symptoms* YES or NO


• Chills
• New or worsening cough (dry or • Headache that is unusual or long-
productive) lasting
• Barking cough (croup) • Runny or stuffy nose (not
• Shortness of breath/difficulty related to seasonal allergies or
breathing other known causes or
• Sore throat conditions)
• Difficulty swallowing • Nausea/vomiting/diarrhea/abdominal
• Loss of taste or smell pain
• Pink eye (conjunctivitis) • Muscle aches
• Unexplained fatigue/malaise
• Falling more than usual
If you have answered:
• Other
• NO to all questions – PASS. You may enter the building and proceed as scheduled.

• YES to any questions from #1 to #4 – FAIL. Put on a surgical mask, go home


immediately and self-isolate. You may work from home if appropriate.
• YES to #5 only – FAIL. Go to question #6.

6. Are these symptoms typical for you (i.e. history of allergies, migraines, other known
1 medical conditions that usually causes these symptoms)?
2
1 • YES – Please self-isolate. Contact your doctor for a note confirming that
3
symptoms are typical before returning to work.
9
• NO – Go home immediately and self-isolate. You may work from home if appropriate.

Screener Signature: Employee Signature:

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