COVID-19 Employee Health-Screening Form

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Employee name: _____________________________________________________

Job title: ____________________________________________________________

Supervisor's name: ____________________________________________________


Date
​Body temperature
​Other symptoms?
(Y/N)
​Screened by




































If an employee's body temperature is at or above 100.4 degrees Fahrenheit, the employee must be sent home immediately and the following completed:

 

Date the employee was sent home: ____________ Recorded temperature: _____________

Are visible signs/symptoms of illness present?  _____ Yes      _____ No

An employee sent home with a fever can return to work when:

  • He or she has had no fever for at least 24 hours without taking medication to reduce fever during that time; AND
  • Any symptoms have improved; AND
  • At least ten days have passed since symptoms began.

 

The employee may return to work earlier if a doctor confirms the cause of the employee's fever or other symptoms is not COVID-19 and provides a written release for the employee to return to work.

 

Date the employee returned to work: _____________________


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