Hospital Food Service Worker Health Template

Personal Information

Full Name Employee ID Department Shift

Health Screening

Date Have you experienced any of the following symptoms? Fever Cough Sore throat Nausea/Vomiting None If yes, please specify Have you been in close contact with anyone diagnosed with a communicable disease? Yes No If yes, details

Hand Hygiene & PPE

Have you performed hand hygiene before starting work? Yes No PPE used

Supervisor Review

Supervisor Name Comments Signature Date