COVID-19 Screening Questionnaire
Full Name
Date
Phone Number
Email Address
Company/Organization
Screening Questions
1. Do you have any of the following symptoms: fever, cough, difficulty breathing, loss of taste or smell?
Yes
No
2. In the past 14 days, have you had close contact with someone who has tested positive for COVID-19?
Yes
No
3. Are you currently awaiting results from a COVID-19 test?
Yes
No
4. In the last 14 days, have you travelled internationally?
Yes
No
Additional Comments