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COVID-19 Employee Screening
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Your Full Name
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1. Have you traveled outside of the Tri-State area within the last 14 days?
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Yes
No
2. If you answered "yes" to question 1, please SPECIFY the state or country name:
3. Have you experienced a fever of 99 degrees Fahrenheit (37.2 degrees Celsius) or greater, chills, a cough, loss of taste or smell, or shortness of breath within the past 10 days?
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Yes
No
4. In the past 10 days, have you tested positive for COVID-19 using a saliva test or a nose or throat swab?
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Yes
No
5. In the past 14 days, have you knowingly been in close contact (within 6 ft) with anyone who tested positive for COVID-19?
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Yes
No
6. Is your body temperature ABOVE 99 degrees Fahrenheit (37.2 degrees Celsius)? Please check your temperature before you leave for work
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Yes
No
Regardless of your answer to question 6, please indicate the temperature you measured, include unit if not Fahrenheit:
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Submit