COVID

Employee First Name (required)

Employee Last Name (required)

Employee Email Address (replace the below with yours for a copy of this document; otherwise leave default [email protected])

Employee Company
ABCEABCIABCLABCPCHEIHTILMPISPIBSPIJSPILSPIR

1. Have you experienced any of the following common symptoms in the past 24 hours?
YesNo

*Fever (above 100.0 degrees Farenheight or above 37.5 degrees Celsius) or chills*Cough (not typical or caused by existing condition)*Shortness of breath/difficulty breathing (not typical or caused by existing condition)*Fatigue (not typical, related to physical activity or caused by existing condition)*Muscle or body aches (not typical, related to physical activity or caused by existing condition)*Headache (not typical or caused by existing condition)*New loss of taste or smell*Sore Throat (not typical or caused by seasonal allergies)*Congestion or runny nose (not typical or caused by seasonal allergies)*Nausea or vomiting*Diarrhea

2. Have you tested positive for COVID-19 or been asked by a medical professional to be tested for COVID-19 in the past 14 days?
YesNo

3. Have you knowingly been in close contact with someone who has been infected with COVID-19 or asked by a medical professional to be tested for COVID-19 in the past 14 days?
YesNo

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