This is a required health screening questionnaire. You must complete this questionnaire at the beginning of your shift. Name * First Name Last Name Contactless Digital Temperature Reading * Must be lower than 100.4°F Have you experienced any of the following symptoms in the last 24 hours? * • Fever or chills • Cough • Shortness of breath or difficulty breathing • Fatigue • Muscle or body aches • Headache • New loss of taste of smell • Sore throat • Congestion or runny nose • Nausea or vomiting • Diarrhea Yes No Within the last 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with: * • Anyone who is known to have laboratory-confirmed COVID-19? OR • Anyone who has symptoms consistent with COVID-19? Yes No Are you isolating or quarantining because you may have been exposed to someone with COVID-19 or are worried that you may be sick with COVID-19? * Yes No Is this the first time returning to work after a period of quarantine or isolation, or have you been out sick for at least two consecutive days? * Yes No Are you fully vaccinated? * Fully vaccinated would mean you have had one dose of the Johnson & Johnson vaccine or two doses of the Pfizer or Moderna vaccines 14 days ago or more. Vaccination status affects quarantine periods. Yes No Have you received a booster shot? * Booster shots are available 6 months after your second MRNA vaccine shot or 2 months after J&J shot. Yes No Has it been 6 months or more since your 2nd Pfizer or Moderna shot or 2 months after your J&J shot? * Yes No Not vaccinated If you answered NO to all questions except the last vaccine question and your temperature is below 100.4°F.If you answered YES to any of the questions except the last vaccine question, please contact your direct supervisor immediately before clocking in. Maintain a six feet distance from staff and guests, and your face covering should stay on over your nose and mouth. Your eligibility to work may require guidance or approval from Human Resources.
