COVID-19 Health Reporting Form for Remote Workers
Full Name
Date
Email Address
Are you currently experiencing any of the following symptoms?
Fever or chills
Cough
Shortness of breath or difficulty breathing
Unusual fatigue
Loss of taste or smell
Sore throat
None of the above
Have you tested positive for COVID-19 in the past 10 days?
Yes
No
Have you been in close contact with anyone who has tested positive for COVID-19 in the past 10 days?
Yes
No
Additional comments or concerns