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COVID-19 Workplace Health Screening
Based on Shiawassee County Health Department Guidance
DISCLAIMER: This screening tool is subject to change based on the latest information on COVID-19
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* Indicates required question
Name of Building
*
Choose
Elementary School
Jr./Sr. High School
Other
Employee Name
*
Your answer
Date
*
MM
/
DD
/
YYYY
Time In
*
Time
:
AM
PM
Do you have any of the following symptoms that are new/different/worse from baseline of any chronic illness.
Fever of 100.4 degrees of higher
*
Yes
No
New or worsening cough
*
Yes
No
Shortness of breath or difficulty breathing - new/different/worse from baseline of any chronic illness
*
Yes
No
Chills - new/different/worse from baseline of any chronic illness
*
Yes
No
Headache (new onset of severe headache, especially with a fever)
*
Yes
No
Sore Throat - new/different/worse from baseline of any chronic illness
*
Yes
No
Loss of smell or taste - new/different/worse from baseline of any chronic illness
*
Yes
No
Muscle pain - new/different/worse from baseline of any chronic illness
*
Yes
No
Had close contact with an individual diagnosed with COVID-19?
*
Yes
No
Are you currently awaiting the results of a Covid-19 test?
Yes
No
Clear selection
Had close contact with an individual who is exhibiting COVID-19 symptoms and is awaiting test results?
Yes
No
Clear selection
If you selected "Yes" for any of the above questions, please contact your direct supervisor for further instructions prior to reporting to work.
By submitting this form, you authorize that the information above is correct.
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