COVID-19 Workplace Entry Self-Assessment Sheet
Full Name
Date
1. Do you have any of the following symptoms?
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Loss of taste or smell
Sore throat
Headache
Congestion or runny nose
Nausea or vomiting
Diarrhea
Yes
No
2. Have you had close contact with anyone confirmed or suspected to have COVID-19 in the last 14 days?
Yes
No
3. Have you tested positive for COVID-19 in the last 14 days?
Yes
No
4. Have you been asked to self-isolate or quarantine by a health authority?
Yes
No
Signature