COVID Symptom Checker Form for Employees


Full Name *

In the last 2 weeks, did you have close contact (within 6 feet) with someone with symptoms of COVID-19, tested for COVID-19, or diagnosed with COVID-19? *
YesNo

Do you have any of the following?

Fever or chills *
YesNo

Cough *
YesNo

Mild difficulty breathing or shortness of breath *
YesNo

Excessive fatigue *
YesNo

Headache *
YesNo

Sore throat *
YesNo

Muscle or body aches *
YesNo

Nausea or vomiting *
YesNo

Diarrhea *
YesNo

Loss of taste or smell *
YesNo

Congestion or runny nose *
YesNo

Other symptoms? Please describe:

If you are feeling sick, stay home and schedule a COVID test. Paid time off is available. We believe it’s better to be safe than sorry!