Teammate Health COVID-19 Screening Form

Employee Number:*
First Name:*
Last Name:*
Date of Birth
Phone Number:*
Email Address:*
Last Date Worked:
Next Scheduled Work Date:
Are you a front line caregiver?  
Have you received the COVID-19 vaccine?  
Reason for contacting Exposure Advisor today (Check all that apply):  
Did you do a virtual visit?
If you are experiencing symptoms (check all that apply) :  

General Concerns or Comments:

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