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?
Yes
No
Have you received the COVID-19 vaccine?
Yes
No
Reason for contacting Exposure Advisor today (Check all that apply):
Close contact with a person under investigation for COVID-19
Close contact with a person with confirmed positive COVID-19
Have you been tested for COVID-19
I have COVID symptoms and believe I need to be tested or re-tested
None of the above reasons
Did you do a virtual visit?
Yes
No
If you are experiencing symptoms (check all that apply) :
New or worsening cough
Sore Throat
Shortness of breath/difficulty breathing
Fever
Headache
Muscle/Body Aches
Loss of Sense of Smell/Taste
Nausea/Vomiting/Diarrhea
Abdominal Pain
Runny Nose/Sinus Congestion
Fatigue
Chills
Repeated shaking with chills
Pain at injection site
Injection site swelling
Fatigue
Malaise
Joint pain
Other
None of the above
General Concerns or Comments: