Construction Site Daily COVID-19 Health Screening Form
Date
Employee Name
Employee ID / Badge #
Company / Contractor Name
1. Do you have any of the following symptoms? (Fever, cough, shortness of breath, sore throat, loss of taste/smell, etc.)
Yes
No
2. Have you been in close contact with anyone diagnosed with COVID-19 in the past 14 days?
Yes
No
3. Have you been instructed to self-isolate or quarantine by a health official?
Yes
No
4. Temperature Check (if required):
Additional Comments
Employee Signature