Employee name: _____________________________________________________
Job title: ____________________________________________________________
Supervisor's name: ____________________________________________________
Date
| Body temperature
| Other symptoms? (Y/N)
| Screened by
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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: _____________________