Employee Self-Assessment Questions

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To help protect ourselves, our families and the residents from potential exposure to the Covid-19 virus, you must complete this survey daily prior to reporting to work.

In the past 14 days have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who:

• Has been diagnosed by a laboratory or physician as COVID-19 positive; or
• Is subject to a Federal, State or Local quarantine or isolation order related to COVID-19; or
• Has been advised by a health care provider to quarantine related to COVID-19

Have you experienced any of the following symptoms in the past 48 hours:

• Cough that cannot be attributed to another health condition
• Shortness of breath/difficulty breathing that cannot be attributed to another health condition
• New loss of sense of taste or smell
• Chills
• Sore throat that cannot be attributed to another health condition
• Fatigue
• Muscle or body aches
• Headache that cannot be attributed to another health condition
• Congestion or runny nose that cannot be attributed to another health condition
• Nausea or vomitting
• Diarrhea

Do you currently have a fever of 100.4 degrees Fahrenheit or higher? (without fever reducing medication)

After completing and submitting this form any employee answering yes to any of the above listed questions must immediately notify their Supervisor/Department Head and will not be permitted to return to work without written medical clearance from a health care provider.

Forms will be housed in employee’s confidential medical file.