Employee COVID-19 Screening Checklist
Employee Name
Date
Symptoms (check all that apply):
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
Loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
In the past 14 days, have you been in close contact with anyone who has tested positive for COVID-19?
Yes
No
In the past 14 days, have you traveled outside of the country or state?
Yes
No
Additional Comments