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Back-to-Work Covid-19 Screening Survey Form
Please take a few moments to complete the form
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Step 1
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Step 2
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Step 3
Employee Name:
First Name
Last Name
This field is required.Please enter value
This field is required.Please enter value
Mobile No:
This field is required.Please enter value
Invalid phone number.
The value must be less than or equal to 20
EMail id:
This field is required.Please enter value
Please enter valid email address
Gender:
Male
Female
This field is required.Please enter value
Are you experiencing any of the following COVID-19 symptoms or combination of symptoms
Cough:
Yes
No
This field is required.Please enter value
Shortness of breath or difficulty breathing:
Yes
No
This field is required.Please enter value
Next
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
New loss of taste or smell:
Yes
No
This field is required.Please enter value
Sore throat:
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
Are you a self-quarantined person?(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 traveled outside your state or regional area:
Yes
No
This field is required.Please enter value
Signature:
This field is required.Please enter value
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Submit
