Healthcare Worker COVID-19 Screening

Full Name

Date

Role/Position

Have you experienced any of the following symptoms in the past 24 hours?

Fever or chills

Yes No

Cough

Yes No

Shortness of breath or difficulty breathing

Yes No

Loss of taste or smell

Yes No

Sore throat

Yes No

Recent Exposure

Have you been in close contact with anyone confirmed to have COVID-19 in the past 14 days?

Yes No

Additional comments