Employee Screening Responses

***COMPLETE THIS ONLY IF EMPLOYEE HAS ONE OR MORE "YES" ANSWERS TO THE QUESTIONS.***

This form is only to be used by admin employees to enter data.

ADM Employee or Field Employee (select one)*
Select or enter value
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Was proper PPE worn and social distancing observed in the office?

1. Has the employee received the COVID-19 Vaccine?*
If yes, what is the Vaccination Type?

2. Within the last 14 days, has the employee experienced a NEW fever or chills, shortness of breath or difficulty breathing, cough, muscle or body aches, fatigue, sore throat, new loss of taste or smell, diarrhea, nausea/vomiting, congestion/runny nose, headache?*


3. Within the last 14 days, has the employee or someone they live with been exposed to an individual with a positive COVID-19 diagnosis?*

If yes, is the employee quarantined?
If exposed by client, was employee wearing PPE?

Select from the dropdown below

Select or enter value
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Was Client wearing a mask?

4. Within the last 14 days, has the employee tested positive for COVID-19?*


Works in a 24 site:*



Please list ALL clients who came in direct contact (within 6ft for a total of 15min in 24 hours) from the period 48 hours before symptom onset to the time at which the employee was isolated.

(if more than one client was exposed)

(if more than one client was exposed)

(if more than one client was exposed)

(if more than one client was exposed)

If more than 3 clients, please include the additional name(s) & exposure date(s) above in Additional Client Exposed box.

Are these client(s) quarantined?

Please submit the Client Response Form for each client listed above who has been exposed to a COVID-19 positive employee.


Did you notify the Health Department?