COVID-19 Self Assessment

Mandatory Daily Employee Self Assessment

In compliance with Federal/State/Corporate Guidelines, a self assessment of your health and social distancing measures must be completed daily prior to your commencing work for the day. If you are sick for any reason, please call your Supervisor / Human Resources and stay home.

Question Title

* 1. Please enter your name.

Question Title

* 2. Do you have a fever with measured temperature of at least 100.4 °F [38 °C]?
A fever may be considered to be present if a person has not had a temperature measurement but feels very warm to the touch, or gives a history of feeling feverish.

Yes

Question Title

* 3. Have you continued to maintain safe social distancing measures and protective PPE as needed?

Yes

Question Title

* 4. Have you been in close contact with anyone that is confirmed to have COVID-19?

Yes

Question Title

* 5. If you answered Yes to question 3. Do you live with this person(s)?

N/A

Yes

Question Title

* 6. If you answered Yes to question 3. Did you provide care to this person(s) while he/she was sick?

N/A

Yes

Question Title

* 7. If Yes to one or more of the above questions, Were you in the same close indoor environment space with the patient for 15 minutes or more during their infectious period?

N/A

Yes

COVID-19 Self Assessment

Mandatory Daily Employee Self Assessment

Question Title

* 1. Please enter your name.

Question Title

* 2. Do you have a fever with measured temperature of at least 100.4 °F [38 °C]?A fever may be considered to be present if a person has not had a temperature measurement but feels very warm to the touch, or gives a history of feeling feverish.

Question Title

* 3. Have you continued to maintain safe social distancing measures and protective PPE as needed?

Question Title

* 4. Have you been in close contact with anyone that is confirmed to have COVID-19?

Question Title

* 5. If you answered Yes to question 3. Do you live with this person(s)?

Question Title

* 6. If you answered Yes to question 3. Did you provide care to this person(s) while he/she was sick?

Question Title

* 7. If Yes to one or more of the above questions, Were you in the same close indoor environment space with the patient for 15 minutes or more during their infectious period?

* 2. Do you have a fever with measured temperature of at least 100.4 °F [38 °C]?
A fever may be considered to be present if a person has not had a temperature measurement but feels very warm to the touch, or gives a history of feeling feverish.