CCCC COVID-19 Health Screening

This Screening Tool is offered for informational purposes to help you check for COVID-19 symptoms as outlined by the Centers for Disease Control. The guidance you receive depends on the accuracy of the information you provide as well as current guidelines for identifying symptoms associated with COVID-19. Please take the survey and provide the response to your employer according to your employer’s instructions.

This is not a substitute for professional medical advice, diagnosis, or treatment of disease or other conditions, including COVID-19. Always consult a medical professional for serious symptoms or emergencies.

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* 1. Date

Date

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* 2. Employee Name

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* 3. Within the last 14 days have you been diagnosed with COVID-19 or had a test confirming you have the virus?

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* 4. Do you live in the same household, or have you had close contact with someone who has been in isolation for COVID-19 or has had a test confirming they have the virus, in the past 14 days?

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* 5. Have you had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by another reason?
Fever (of at least 100.4° (38°C) or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore Throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

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* 6. Have you or someone you've been in contact with traveled domestically or internationally in the last 14 days?

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* 7. Have you or someone you've been in contact with attended a gathering where proper social distancing protocol was not followed in the past 14 days?

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* 8. I confirm the responses provided above are true, complete and accurate to the best of my knowledge.

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* 9. I confirm I will follow my employer's COVID-19 policy.

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* 10. I confirm I have checked my temperature this morning and it was not above 100.4°.

If you answered "YES" or "I Do Not Confirm" to any question, you should do the following:
Do not report to work or immediately leave the building and notify your Supervisor and the Human Resources Manager.

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