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Coronavirus Disease (COVID-19 Workplace Health Screening Company Name: Employee Name: Date: Time In: In the past 24 hours, have you experienced: Yes No Yes No Yes No Yes No Yes No Subjective fever (felt feverish): New or worsening cough: Shortness of breath: Sore throat: Vomiting/Diarrhea: Current temperature: If you answer “yes” to any of the listed above, or your temperature is 100.4°F or higher, please do not go into work. Self- isolate at home and contact your primary care physician’s office for direction. • You should isolate at home for minimum of 7 days since first appear. • You must also have 3 days without fevers and improvement in respiratory Yes No Yes No Have you had close contact in the last 14 days with an individual diagnosed with COVID-19? Have you engaged in any activity or travel within the last 14 days which fails to comply with the Stay Home, Stay Safe Executive Order? Have you been directed or told by the local health department or your healthcare provider to self-isolate or self- quarantine? Yes No If you answer “yes” to either of these questions, please do not go into work. Self-quarantine at home for 14 days.