Food Pantry COVID-19 Screening Checklist
Screening Information
Name:
Date:
Symptoms Checklist
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
Exposure Checklist
Contact with anyone with confirmed COVID-19 in the past 14 days
Signature
Print Name: