COVID-19 SCREENING COVID 19 Screen Covid-19 Screening questions Covid-19 Screening Protocol: Optional Survey for Employee Self-administrationName* First Last Email* PhoneDate* MM slash DD slash YYYY Yes, or No, Since your last day at work or your last visit to this establishment, have you had any of the following symptoms?A: A new fever of (100.4' or higher) or a sense of having a fever* yes no B: A new cough that can not be attributed to another health condition* yes no C: New shortness of breath or difficulty breathing that cannot be attrbuted to another health condition.* yes no D: New chills that cannot be attributed to another condition* yes no E: A sore throat that cannot be attributed to another condition.* yes no F: New muscle aches (Myalgia) that cannot be attributed to another health condition, or that may have been caused by specific activities, such as physical exercise* yes no G: Recent loss of taste and smell* yes no H: Have you have a positive result for the virus that causes Covid-19 in the past 10 days?* yes no I: In the past 14 days, have you had close contact (within 6 feet for 15 minutes or longer) with someone suspected or confirmed to have Covid-19?* yes no COVID-19 Optional Employee Agreement: Infection Control Practices during your time in this establishment. Do you agree to:J: Immediately notify your instructor if you develop symptoms of COVID-19* yes no K: Practice proper hand hygiene* yes no L: Maintain appropoiate physical distance between yourself and others, as much as possible (at least 10 feet for establishments with physical activity, singing, cheering and at least 6 feet for all other activities)* yes no M: Limit physical contact between yourself and others, as much as possible* yes no N: Wear a face mask when unable to maintain a distance of 6 feet or more between yourself and others* yes no O: Limit touching surfaces to only when its neccessary* yes no CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
