PUMP N PANTRY COVID-19 EMPLOYEE RESOURCES Pre-Work Screening Questionnaire ALL-EMPLOYEES-DAILY COVID-19 SCREENING QUESTONAIRE **THIS FORM MUST BE COMPLETED BY EVERY EMPLOYEE WHO ENTERS A STORE EACH DAY** Name* First Last Store*MontroseGreat BendNew MilfordDushoreNicholsonTunkhannock RT 6LenoxTunkhannock RT 29Lake WinolaPikes CreekTroyMansfieldTiogaCantonCorporate OfficeDate* MM slash DD slash YYYY Time* : Hours Minutes AM PM 1. DO YOU HAVE ANY SIGNS OR SYMPTOMS OF RESPIRATORY INFECTION? (check all that apply)* Unexplained cough or tightness of chest Fever or have taken fever reducing medicine in the last 24 hours Shortness of Breath Sore Throat No, I am not experiencing any of the above symptoms My current Temperature in Fahrenheit is:*Temperature must be less than 100 degrees to continue to work.2. My current temperature is:*Select onedid not take temperature100 degrees or aboveless than 100 degreesSignature*By signing, I confirm that I have answered the above questions honestly and that if I develop signs or symptoms of respiratory illness, including fever, cough, shortness of breath, or sore throat that I will contact the store manager. Δ
