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Return-to-Work Feedback Form
Please spend a few minutes to complete this COVID-19 survey
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Step 1
2
Step 2
3
Step 3
*
Employee Full Name:
*
First Name
*
Last Name
this field is required.Please Enter Value
this field is required.Please Enter Value
*
Email id:
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Please Enter the Valid Email Address
Mobile No:
this field is required.Please Enter Value
Invalid phone number.
The value must be less than or equal to 20
Are you experiencing any of the following COVID-19 symptoms or combination of symptoms
*
Shortness of breath or difficulty breathing:
Yes
No
this field is required.Please Enter Value
*
Cough:
Yes
No
this field is required.Please Enter Value
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Or at least two of these symptoms
*
Fever (100.4 degrees or higher):
Yes
No
this field is required.Please Enter Value
Chills:
Yes
No
this field is required.Please Enter Value
Repeated shaking with chills:
Yes
No
this field is required.Please Enter Value
Muscle pain:
Yes
No
this field is required.Please Enter Value
*
Headache:
Yes
No
this field is required.Please Enter Value
Sore throat:
Yes
No
this field is required.Please Enter Value
*
New loss of taste or smell:
Yes
No
this field is required.Please Enter Value
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Additional questions
*
Are you currently waiting for COVID-19 test results:
Yes
No
this field is required.Please Enter Value
*
Have you tested positive for COVID-19:
Yes
No
this field is required.Please Enter Value
Have you self-quarantined, (remaining in your home and outdoor activities without coming closer than 6-feet from others):
Yes
No
this field is required.Please Enter Value
*
Have you been exposed to anyone currently waiting for COVID-19 test results:
Yes
No
this field is required.Please Enter Value
*
Have you been exposed to anyone who has tested positive for COVID-19:
Yes
No
this field is required.Please Enter Value
Have you been exposed to anyone with any of the CDC specified symptoms (see above):
Yes
No
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*
Have you traveled outside your state or regional area:
Yes
No
this field is required.Please Enter Value
Comments/Suggestions :
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Signature:
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