COVID-19 Assessment Employee - JD

To preserve the health of our patients and employees, please complete the following assessment regarding COVID-19. Your responses will help us prevent any unnecessary exposure. Please let us know if you have and questions. Thank you!

Name:*

Date of Birth:

Gender:

Female Male

Have you been exposed to anyone who has tested positive for COVID-19 in the last two weeks?*

Yes No

Have any members of your household been exposed to anyone who has tested positive for COVID-19 in the last two weeks?*

Yes No

Have you been exposed to anyone who has, or has had any symptoms associated with COVID-19 in the last two weeks? (e.g. dry cough, fever, shortness of breath)*

Yes No

Do any members of your household currently have, or have had, any symptoms associated with COVID-19? (e.g. dry cough, fever, shortness of breath)*

Yes No

Have any members of your household been exposed to anyone who has, or has had any symptoms associated with COVID-19 in the last two weeks? (e.g. dry cough, fever, shortness of breath)*

Yes No

Have you been advised to seek COVID-19 testing by another healthcare professional in the last two weeks?*

Yes No

7. Have you been advised to self-quarantine by another healthcare provider in the last two weeks?*

Yes No

Employee Signature:*

[clear]

Use your mouse or finger to draw your signature above

Practice Coordinator:

Date:

Temperature:

COVID-19 EMPLOYEE ASSESSMENT