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!