COVID‐19 Team Member Screen/Disclosure Name* First Last Date* Date Format: MM slash DD slash YYYY Do you have a fever or feeling feverish?*YesNoDo you have shortness of breath?*YesNoDo you have a NEW cough?*YesNoDo you have a NEW sore throat?*YesNoDo you have a NEW loss of smell or taste?*YesNoDo you have a NEW headache?*YesNoDo you have chills or muscle aches?*YesNoHave you been in close contact (within 6 feet for at least a cumulative of 15 minutes) with anyone that has tested positive for COVID-19?*YesNoEmployee Signature*Date* Date Format: MM slash DD slash YYYY Witness Signature*Date* Date Format: MM slash DD slash YYYY
