Teammate Health COVID-19 Screening Form

Employee Number:*
First Name:*
Last Name:*
Date of Birth
(mm/dd/yyyy):*
 
Phone Number:*
Email Address:*
Last Date Worked:
(mm/dd/yyyy):*
 
Next Scheduled Work Date:
(mm/dd/yyyy):*
 
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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