Health Assessment

Will you be at work today?

• Yes

• No

Please select a reason.

• PTO or vacation

• Sick leave or FMLA

• Paid administrative leave

• Other

Enter an estimated return date.

In the past 14 days, have you tested positive for COVID-19?

• Yes

• No

In the past 14 days, have you been exposed to someone who tested positive or had symptoms of COVID-19?

• Yes

• No

In the past 14 days have you traveled internationally or to a high risk COVID state?

• Yes

• No

In the past 14 days, have you:

• Traveled internationally
• Traveled to a high risk COVID state
• Been exposed to someone who tested positive for COVID-19
• None

Have you had any new and unexpected COVID-19 symptoms within the past 24 hours?

• Temperature of 100.4F or higher
• Cough
• Trouble breathing, shortness of breath, or severe wheezing
• Muscle aches
• Sore throat (not due to allergies)
• Loss of smell or taste, or change in taste
• Nausea, vomiting, or diarrhea
• Headache
• Congestion or runny nose
• Loss of appetite
• Severe fatigue
• None