Business Office Resources

Covid Screening From

Date

MM

DD

YYYY

Recorded Temperature

Confirmatory Temperature

If above 100.4°F/38°C, perform a confirmatory check by using a backup thermometer.

Employee/Visitor/Volunteer Name

First Name

Last Name

Phone # or Email

for contact tracing if needed

Have you traveled out of the country within the last 14 days?

Yes

No

Have you been exposed to someone diagnosed with Covid-19 within the last 14 days?

Yes

No

Have you experienced a new cough, shortness of breath, sore throat, chills, muscle pain, or a new loss of taste or smell that cannot attribute to another health condition?

Yes

No

If an employee or visitor has a temperature above 100.4F or answers YES to any of the screening questions, follow the below instructions:

If an employee or visitor has a temperature above 100.4°F or answers YES to any of the screening questions, immediately activate our emergency protocol for COVID-19. The employee must be sent home and be advised to contact their supervisor and recommend medical follow-up. The employee will be given the COVID-19 Return to Work Form. Visitors will not be allowed to enter the building. An employee who is sent home can return to work when each of the following conditions have been met: • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and • Improvement in respiratory symptoms (e.g., cough, shortness of breath); and, • At least 7 days have passed since symptoms first appeared. An employee may return to work without meeting the conditions set forth above if a doctor confirms the cause of the employee’s symptoms is not COVID-19 related and provides a written release for the employee to return to work.

Screener Name or Initials