Name

First Name

Last Name

1. Have you had close contact (within 6 feet for at least 10 minutes) in the last 14 days with someone diagnosed with COVID-19, or has any health department or health care provider been in contact with you and advised you to quarantine?

Yes: The worker should not work. The worker can return 14 days after the last time they had close contact with someone with COVID-19, or as listed below.

2. Since you last worked, have you had any of these symptoms?

If a worker has any of these symptoms, they should go home, stay away from other people, and call their health care provider.

Fever

Chills

Shortness of breath or difficulty breathing

New cough

New loss of taste or smell

3. Since you last worked, have you been diagnosed with COVID-19?

If a worker is diagnosed with COVID-19 based on a test or their symptoms or does not get a COVID-19 test but has had symptoms, they should not work and stay at home.

Returning To Work

A worker can return to work when they can answer YES to ALL three questions: -Has it been at least 10 days since you first had symptoms? -Has it been at least 3 days since you’ve had a fever (without using fever reducing medicine)? -Has it been at least 3 days since your symptoms have improved, including cough and shortness of breath? If an employee has had a negative COVID-19 test, they can return to work once they have no fever without the use of fever-reducing medicines and have felt well for 24 hours. The employee can return to work without meeting the above criteria and without a negative COVID-19 test result IF they have a doctor’s note allowing them to return to work.

Symptoms Screening Checklist

LOCATION