Daily Health Assessment Form

All staff who physically report to work are required to complete the Daily Health Assessment Form and submit it prior to reporting to work. After submitting the form, your department head will be notified of your submission and work status.

If you are exhibiting symptoms of an infectious disease, you are required to stay at home and your director will be notified. Please call your immediate supervisor to report your work status.

In the last day, or since your last work day (if less than 14 days ago) have you experienced either:

a) Any cold or flu-like symptoms including fever (100.4 degrees or higher)
b) New, unexplained onset of any of the following:
    (Cough | Shortness of breath | Sore throat | Unexplained muscle aches) *
In the last 14 days, have you had contact with any person outside of work who is either:

a) Symptomatic and being investigated for COVID-19
b) Confirmed positive for COVID-19 *
In the past 14 days have you:

a) Been referred for COVID-19 testing by a health care provider
b) Tested positive for COVID-19
c) Been awaiting COVID-19 test results
d) Been advised by a health care provider that you may have COVID-19

NOTE: Do not include negative COVID-19 test results that are received as part of an admission screening for a routine medical procedure such as a colonoscopy, eye surgery, dental visit, etc. *