COVID-19 Employee Form

Name *

First

Last

Phone *

Email *

Manager *

Please answer "yes" or "no" if you are experiencing any of the following symptoms unrelated to a pre-existing medical condition.

Body Temperature *

Cough *

Excluding chronic cough due to a known medical reason unrelated to COVID-19

Shortness of Breath *

Sore Throat *

Diarrhea *

Excluding diarrhea for known medical reason

Chills *

New Loss of Taste or Smell *

In the last 14 days have you knowingly had close contact with someone with a positive diagnosis of COVID-19? *

In the last 14 days have you travelled via airplane internationally or domestically? *

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