COVID-19 Contractor Screening
This questionnaire must be completed DAILY prior to the start of their work shift or before entering client premises. If you answer "Yes" to any of the questions below, please contact your supervisor immediately, and do not report to work. If you start to feel sick during your shift, go home and contact your supervisor. Please direct all questions and concerns @(347-216-4927)
Sign in to Google to save your progress. Learn more
Full Name *
Assigned Work Address *
Do you currently have a fever (temperature of 100.4 F or greater) without having taken any fever-reducing medications? *
Have you experienced any of the following COVID-19 related symptoms in the past 14 days: cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, sore throat, or new loss of taste or smell? *
Have you tested positive for COVID-19 in the past 14 days, or have you been instructed by a health care professional/public health official/contact tracing app to self-isolate or quarantine? *
Have you tested positive for COVID-19 in the past 14 days, or have you been instructed by a health care professional/public health official/contact tracing app to self-isolate or quarantine? *
Have you knowingly been in close (within 6 feet) or proximate (same enclosed environment, such as an office, but greater than 6 feet) contact with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19 within the past 14 days? *
Have you knowingly been in close (within 6 feet) or proximate (same enclosed environment, such as an office, but greater than 6 feet) contact with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19 within the past 14 days? *
Have you, or anyone you live with, traveled outside New York State in the last 14 days? *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms