COVID-19 Employee Screening – Hand Held Films

Your Full Name *

1. Have you traveled outside of the Tri-State area within the last 14 days? *

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? *

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? *

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? *

Yes
No

6. Is your body temperature ABOVE 99 degrees Fahrenheit (37.2 degrees Celsius)? Please check your temperature before you leave for work *

Yes
No

Regardless of your answer to question 6, please indicate the temperature you measured, include unit if not Fahrenheit: *