Coronavirus Disease (COVID-19) Workplace Health Screening

To comply with the Mid-Michigan District Health Department Emergency Order 2020-2, the CRAA has adopted this electronic workplace health screening form. Completion of this screening must occur prior to the start of each shift, preferably before each employee has entered any CRAA workspace. This is intended to minimize potential exposures and to maintain a safe environment for all CRAA employees.

If there are any questions or concerns regarding the CRAA's COVID-19 response, please contact your immediate supervisor and/or Sophie Giviyan, Finance Director. Additional information is available at www.mmdhd.org or contact Mid-Michigan District Health Department at Clinton County: 989-224-2195, in Gratiot County: 989-875-3681 and in Montcalm County: 989-831-5237.

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* 1. Employee Name

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* 2. Date

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* 3. Time In

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* 4. In the past 14 days, have you had any of the following symptoms develop or worsen with no other known cause:

If you answer "yes" to any of the symptoms listed below, or your temperature is 100.4 degrees or higher (100 degrees if working as a health care provider), do not go into work. Self-isolate (stay) at home and contact your health care provider for direction.

- You should self-isolate (stay) as directed by your health care provider or health department. This is typically for 10 days after your symptoms started and after you have gone 3 days without a fever and 3 days with improving respiratory symptoms.

	Yes	No
Fever or felt feverish	Fever or felt feverish Yes	Fever or felt feverish No
Cough	Cough Yes	Cough No
Shortness of breath/difficulty breathing	Shortness of breath/difficulty breathing Yes	Shortness of breath/difficulty breathing No
Sore throat	Sore throat Yes	Sore throat No
Diarrhea	Diarrhea Yes	Diarrhea No
Chills	Chills Yes	Chills No
Muscle pain	Muscle pain Yes	Muscle pain No
New loss of taste or smell	New loss of taste or smell Yes	New loss of taste or smell No

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* 5. Current temperature (if known)

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* 6. In the past 14 days, have you:

If you answer "yes" to either of these questions, do not go into work. Self-quarantine at home for 14 days or as directed by the health department.

	Yes	No
Had close contact with an individual diagnosed with COVID-19?	Had close contact with an individual diagnosed with COVID-19? Yes	Had close contact with an individual diagnosed with COVID-19? No
Traveled internationally or taken a cruise?	Traveled internationally or taken a cruise? Yes	Traveled internationally or taken a cruise? No

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* 7. Are you an employee or a contractor?

Employee

Contractor

Employee

Contractor

Coronavirus Disease (COVID-19) Workplace Health Screening

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* 1. Employee Name

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* 2. Date

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* 3. Time In

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* 5. Current temperature (if known)

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* 6. In the past 14 days, have you:If you answer "yes" to either of these questions, do not go into work. Self-quarantine at home for 14 days or as directed by the health department.

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* 7. Are you an employee or a contractor?

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* 8. If a contractor, please provide the company name.

* 6. In the past 14 days, have you:

If you answer "yes" to either of these questions, do not go into work. Self-quarantine at home for 14 days or as directed by the health department.