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!