COVID-19 Self Assessment

COVID-19 Screening Checklist

All employees and visitors entering the building should be asked following questions.

COVID-19 Screening Checklist for Non-Medical Employers

All employees and visitors entering the building should be asked following questions. Screening should be done at the beginning and at the end of the workday.

Store Location*

Full Name*

1. Do yo have fever?*

Yes

2. Do you have any of the following respiratory symptoms?*

Cough (productive or dry)

Sore Throat

Runny nose

None of the above

3. Have you had close, unprotected contact with a suspected or known COVID-19 patient (spent longer than 15 mins within 6 feet of someone who was sick with a fever and cough)?*

Yes - Go home immediately and self-isolate for 14 days if asymptomatic

No - Continue to next question

4. If they have subjective or documented fever OR any of the respiratory symtoms OR close contact with COVID-19 patient noted above:*

They should be asked to go home immediately and self-isolate until they are asymptomatic for 3 days without the use of any medications, and it has been 7 days since the first day of their symptoms (whichever duration is longer)

5. If they say No to #1, #2 and #3, they can work but remind them to the following:

Wash their hands with soap and water or alcohol-based sanitizer before they start work and frequently throughout the day

Practice social distancing, sit and/or stand at least 6 ft from other people, donot shake hands or hug people, and do not share food or drinks

Sanitize their work area before they leave

Contact their employer and leave work immediately if they start to feel feverish or have respiratory symptoms