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Employee Evaluation Checklist Form
Please fill the form below
1
Step 1
2
Step 2
Employee Name:
First Name
Last Name
This field is required.Please enter value
This field is required.Please enter value
Employee ID:
This field is required.Please enter value
The value allows only numbers
Invalid number!
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Date Of Screening:
This field is required.Please enter value
Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Date Of Birth:
This field is required.Please enter value
Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Mobile No:
This field is required.Please enter value
Invalid phone number.
The value must be less than or equal to 20
Age:
This field is required.Please enter value
The value allows only numbers
Invalid number!
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
EMail id:
This field is required.Please enter value
Please enter valid email address
Gender:
Male
Female
This field is required.Please enter value
Initial Temperature:
This field is required.Please enter value
Temp. @ 1 Min:
This field is required.Please enter value
Temp. @ 2 Min:
This field is required.Please enter value
Temperature at 1 Minute
Temperature at 2 Minute
Employee feels Sick:
Yes
No
This field is required.Please enter value
If Yes, explain:
This field is required.Please enter value
Next
Are you using any of the following
Cold Medicine:
Yes
No
This field is required.Please enter value
Any Pain Killers:
Yes
No
This field is required.Please enter value
Have you had any contact with anyone suspected with COVID-19:
Yes
No
This field is required.Please enter value
If YES, explain:
This field is required.Please enter value
Does the employee have any of the following symptoms? Check YES or NO
Cough:
Yes
No
This field is required.Please enter value
If YES, explain:
This field is required.Please enter value
Sore throat:
Yes
No
This field is required.Please enter value
High Fever:
Yes
No
This field is required.Please enter value
Digestive Issues:
Yes
No
This field is required.Please enter value
Shortness of Breath:
Yes
No
This field is required.Please enter value
Screener Name:
First Name
Last Name
This field is required.Please enter value
This field is required.Please enter value
Employee Result:
Green
Yellow
Red
This field is required.Please enter value
Completion Time:
This field is required.Please enter value
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Sign here (If on phone or tablet use your finger to sign):
This field is required.Please enter value
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