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Employee Illness/Infection Screening

1.Please enter your full name:
2.What is your position at Andrew?
3.On which floor do you typically work?
4.What symptoms are you currently experiencing?
5.When did your symptoms first appear?
DATE/TIME
Time
:
6.Have you been around anyone else with these sympotoms?
7.Have you had any recent exposure to COVID-19?
8.Have you completed any testing for COVID-19?
9.If yes, what were the results of your COVID-19 test?
10.What date did you take the COVID-19 test?
11.Have you completed any additional diagnostic testing?
12.If yes, what type of testing?
13.What were the results?
14.When was the last shift you worked?
DATE / TIME
Time
:
15.Please enter a phone number where you can be reached:
16.Is the phone number provided able to receive and send texts?
17.If applicable, please provide any additional details or comments (diagnosis, chronic conditions, etc):
- If you have a fever, you must wait until you have been fever-free for at least 24 hours before returning to work.
- If you are experiencing vomiting or diarrhea related to a GI illness, it is advised you do not return to work until 24 hours after the last episode, and at least 72 hours from the start of the illness.
- The Infection Preventionist or designee will review your submitted questionnaire. They may need to contact you if further details are needed.