COVID-19 Screening Survey for Employees

COVID-19 Screening Form
COVID-19 Intake Form
Instructions for Completion: Please complete Notification of COVID-19 related travel or symptom exposure
COVID-19 Travel & Symptom Screening/Intake
Today's Date:
***To be used for screening those returning from travel, with community exposure or signs & symptoms***


Have your traveled recently to a Tier 2 or 3 country/state per CDC or been on a Cruise in last 14 days:
Have you had close contact with a person under investigation or laboratory confirmed COVID-19:
1. Have you experienced fever or signs/symptoms of lower respiratory illness (e.g., cough or shortness of breath)?
3. Please check all symptoms that you are experiencing, and date of onset for each:
Loss of smell and/or taste
Sore throat
Shortness of breath
4. Have you been vaccinated?
5. Please check any other symptoms you are also experiencing:

Risk level to be completed by Employee Health

Risk Level Assignment: