COVID-19 SCREENING RESOURCE

DAILY COVID-19 SCREENING QUESTONAIRE **THIS FORM MUST BE COMPLETED BY EVERY PERSON WHO ENTERS THE ROOM EACH DAY**

Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
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:*
Signature*
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 person in charge.