Thank you for filling the form.
Entries limit is exceeded! Please contact your administrator.
"Sorry! User can't post a new entry"
Space limit is exceeded! Please contact your administrator.
"Sorry! User can't post a new entry"
Plan is expired! Please contact your administrator.
"Sorry! User can't post a new entry"
Staff Observations Questionnaire Form
Please fill out the COVID-19 form carefully
Employee Name:
First Name
Last Name
This field is required.Please enter value
This field is required.Please enter value
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
*
Temperature:
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
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
Mobile No:
This field is required.Please enter value
Invalid phone number.
The value must be less than or equal to 20
Gender:
Male
Female
This field is required.Please enter value
Please review the following self screening criteria:
Yes
No
Have you or anyone in the family (household) tested positive for COVID-19
Have you or anyone in the family (household) been tested for COVID-19 and are waiting for results
Do you or anyone in the family (household) have any of the following respiratory symptoms, Fever, Sore Throat, Cough, Shortness of Breath
Have you or anyone in the family (household recently lost your sense of smell or taste
Do you or anyone in the family (household) have any GI symptoms, Diarrhea, Nausea
Even if you don’t currently have any of the above symptoms, have you or anyone in the family (household) experienced any of these symptoms in the last 14 days
Have you or anyone in the family (household) traveled outside the air or cruise ship in the past 14 days
Have you or anyone in the family (household) traveled within the air, bus or train within the past 14 days
Signature:
This field is required.Please enter value
Submit
