Checkin

COVID-19 Questionnaire

All questions must be answered to submit the form.

PLEASE ANSWER ALL QUESTIONS BELOW

1. Do you have any of the following symptoms? 1a. Persistent cough*

No Yes

1b. Difficulty breathing*

No Yes

1c. Fever*

No Yes

1d. Chills/shaking*

No Yes

1e. Loss of taste or smell*

No Yes

2. In the last 14 days, have you had personal close contact with (live with, provide direct care for or been within six feet of for more than 15 minutes) anyone who is known to have COVID-19, suspected to have COVID-19, or is awaiting COVID-19 test results?*

No Yes

2a. Has the individual been fever-free for at least 72 hours (three full days of no fever without the use of fever-reducing medicine)?

No Yes

2b. Have all symptoms (cough, shortness of breath, etc.) improved?

No Yes

2c. Have at least seven days passed since their symptoms occurred?

No Yes

3. Have you traveled internationally in the past 14 days?*

No Yes

3a. If you have traveled internationally in the past 14 days, where have you traveled?

3b. If you have traveled internationally in the past 14 days, what was the date of your return to the United States?

4. Have you tested positive for COVID-19, been told by a medical professional that you have had COVID-19, or are you awaiting pending results of a COVID-19 test?*

No Yes

4a. Have you completed your 10-day isolation period and have you been fever-free for 72 hours without the use of fever-reducing medication?

No Yes

Project Site Check In

Employee or Visitor Name

Employee or Visitor Contact Information

COVID-19 Questionnaire

PLEASE ANSWER ALL QUESTIONS BELOW