Seafood Processing Plant
Employee Health Checklist
Employee Information
Name:
Employee ID:
Date:
Supervisor:
Symptom Check
Fever
Cough
Shortness of Breath
Sore Throat
Nausea / Vomiting
Diarrhea
Other Symptoms
If Other Symptoms, please specify:
Exposure History
Close contact with confirmed illness in past 14 days
Recent travel to affected area
If Yes to any, please provide details:
Employee Statement
Signature:
Date:
For Supervisor Use Only
Notes:
Supervisor Signature:
Date: