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Covid-19 Screening


Please fill out the form below. Thank you!

Employee Name:
I utilized the temperature self-screening device at:
I DO NOT have a temperature of 100 degrees or higher?
True False
Temperature reading:

I AM NOT currently experiencing any of the following symtoms that are related to COVID19

  • Fever above 100 degrees F
  • Cough
  • Shortness of breath or difficulty breathing
  • Severe headache
  • Loss of Taste or smell
  • Nausea or vomiting
  • Diarrhea
True False
By submitting this form, I hereby declare that, to the best of my knowledge and belief, all information in the above referenced data reported is accurate and complete. I understand that any misrepresentation, falsification, or omission of any facts called for in the information provided may render this application void and will be cause for disciplinary action, whenever discovered. I have not been coerced, threatened, or intimidated into submitting this information; instead, it is of my own free will.