Employee Health Test

First Name *

Last Name *

Date *

Have you received your Covid-19 vaccine? *

Yes

No

Did you vomit in the last 24 hours? *

Yes

No

Have you had diarrhea in the last 24 hours? *

Yes

No

Have you experienced shortness of breath in the last 24 hours? *

Yes

No

Have you had a persistent cough in the last 24 hours? *

Yes

No

Have you come in contact with a person positive for COVID-19 in the last 24 hours? *

Yes

No

Unknown

Have you had a fever or felt feverish in last 24 hours? *

Yes

No

Please record your temperature here if available

Please record any COVID-19 related symptoms you have experienced in the last 24 hours

If you are human, leave this field blank.

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