COVID-19 Employee Screening

Today's Date * +

Time *

First Name *

Last Name *

Phone Number *

Email Address *

Have you been diagnosed with COVID-19 in the last 14 days? *

Yes

No

Have you been in close contact with anyone diagnosed with COVID-19 in the last 14 days? *

Yes

No

Are you currently experiencing COVID-19 symptoms, including fever, cough, sore throat, respiratory illness, shortness of breath, diarrhea, or any other cold/flu symptoms? *

Yes

No

Have you traveled via airplane internationally or domestically in the last 14 days? *

Yes

No

I hereby certify that the above information is accurate to the best of my knowledge *

Yes