EMPLOYEE COVID QUESTIONNAIRE

Have you experienced a fever of 100.4 or greater and/or a new unexplained cough associated with shortness of breath?(required)

Yes No

Have you experienced new loss of taste and/or smell with no other explanation?(required)

Yes No

Have you tested positive for COVID-19 in the past 10 days?(required)

Yes No

Are you currently awaiting results from a COVID-19 test?(required)

Yes No

Have you been told that you are suspected OR have been diagnosed with COVID-19 by a licensed healthcare provider (for example, doctor, nurse, pharmacist or other) in the past 10 days?(required)

Yes No