Symptom Checklist to be completed daily prior to working on site.

Please take your temperature at home and record it below 
If you answer yes to any question or have a temperature of 100.4 or greater your next step is to call your supervisor.

In most circumstances after this call, the procedure will be to self-isolate at home and contact your physician for direction.

Please record your name and today's date, then respond to questions 3 through 12 answering the symptom screening questions:

 In the past 24 hours have you ...

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* 1. Name

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* 2. Today's Date

Date
Time

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* 3. Felt feverish?

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* 4. Developed a new or worsening cough?

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* 5. Experienced shortness of breath?

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* 6. Developed a sore throat?

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* 7. Experienced vomiting or diarrhea?

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* 8. Experienced repeated shaking with chills?

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* 9. Experienced a new loss of taste or smell?

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* 10. Had muscle pain?

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* 11. Had a headache?

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* 12. Had suspected or confirmed exposure to people with possible COVID-19?

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* 13. Please record your temperature

T