COVID-19 Self-Screening Questionnaire
An outbreak of 2019 Coronavirus (COVID-19) requires early and effective detection of suspected cases to limit the risk of exposure to others. We are requesting you to complete the following questions and to have your temperature checked by us.
Employee Name: _____________________________
Date:__________________________________________
You MUST wash your hands or use alcohol-based hand rub on entry? Y N
If no, (ask them to do so)
If no, (ask them to do so)
Within the last 24 hours, have you had any of the following symptoms? (Circle Y or N)
Fever/Chills Y N Cough Y N
Shortness of Breath Y N Difficulty Breathing Y N
Sore Throat Y N
If you have any of the symptoms listed above, you are immediately required to contact your medical provider and are not to enter the BLE facility.
Fever/Chills Y N Cough Y N
Shortness of Breath Y N Difficulty Breathing Y N
Sore Throat Y N
If you have any of the symptoms listed above, you are immediately required to contact your medical provider and are not to enter the BLE facility.
Please make sure to wash your hands or use hand sanitizer while you are at the site. DO NOT shake hands with, touch or get within six feet of other individuals while you are here.