Teammate Health COVID-19 Screening Form
Date of Birth
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):
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?
If you are experiencing symptoms (check all that apply) :
New or worsening cough
Shortness of breath/difficulty breathing
Loss of Sense of Smell/Taste
Runny Nose/Sinus Congestion
Repeated shaking with chills
Pain at injection site
Injection site swelling
None of the above
General Concerns or Comments: