Employee COVID-19 Screening Questionnaire

Employee Covid-19 Screening Questionnaire

Safety is our overriding priority. As COVID-19 continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread and reduce the potential risk of exposure every employee is required to complete this questionnaire daily prior to the start of their shift.



1.) Are you experiencing any of the following symptoms? (Please take your temperature before you answer this question.)

2.) Have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?

3.) Have you been in close proximity to anyone who has tested positive for COVID-19?

4.) Have you been tested for COVID-19 and are waiting to receive test results?


I hereby certify that the responses provided above are true and accurate to the best of my knowledge.