Illness Reporting
EMPLOYEE NAME
Enter Date of Birth
DEPARTMENT
TODAY'S DATE
check if you have a FEVER
check if you have a COUGH
check if you have CONGESTION/RUNNY NOSE
check if you have a NAUSEA OR VOMITTING OR DIARRHEA
check if you have a SORE THROAT
check if you have ACHES OR CHILLS OR RIGORS
check if you have a HEADACHE
check if you have a RASH
Other
Are you living with someone that has COVID-19? If yes, when did they start symptoms?
Are you Scheduled to work within the next 24 hours?
Have you worked within the last 2 days?
WHEN DID YOUR SYMPTOMS START
DID YOU HAVE A RECENT EXPOSURE TO COVID-19, IF YES. PLEASE EXPLAIN
Please write your email address
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phone number
Phone
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