COVID‐19 Team Member Screen/Disclosure in Lakeville, MN

Name*

First Last

Date*

Current Temp.*

Have you experienced fever greater than 100.0 oF in the last 14 days*

Yes
No

Have you experienced fever greater than 100.0 oF in the last 14 days*

Yes
No

Have you had a cough, shortness of breath, chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell in the last 14 days?*

Yes
No

Have you traveled out of country or out of state in the last 14 days?*

Yes
No

Have you been in contact with anyone who tested positive or is suspected positive for COVID-19?*

Yes
No

Do you have any symptoms (cough, shortness of breath, achiness)?*

Yes
No

Employee Signature*

Date*

Witness Signature*

Date*

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