School Cafeteria Food Handler Screening Form
Full Name
Job Position
Date
School Name
1. Are you currently experiencing any of the following symptoms?
Fever
Cough
Vomiting
Diarrhea
Sore Throat
Other symptoms:
2. Have you been diagnosed with any communicable disease in the past month?
Yes
No
If yes, please specify
3. In the past 48 hours, have you had contact with anyone with confirmed or suspected communicable diseases?
Yes
No
If yes, please provide details
4. Attestation
I affirm the above information is accurate to the best of my knowledge.
Signature
Date