COVID-19 Temporary Staff Symptom Checklist

Name

Date

Employee ID

Shift Time

Symptoms Checklist

Fever or chills Cough Shortness of breath or difficulty breathing Sore throat Muscle or body aches Fatigue Headache New loss of taste or smell Congestion or runny nose Nausea or vomiting Diarrhea

Exposure Screening

In the past 14 days, have you been in close contact with someone diagnosed with COVID-19?

Additional Notes