Ourisman FT Daily Wellness Check
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IF YOU ANSWER "YES" TO ANY OF THE FOLLOWING QUESTIONS, PLEASE CONTACT YOUR SUPERVISOR IMMEDIATELY AND DO NOT REPORT FOR WORK.
First Name *
Last Name *
Employee Number *
Department *
Date *
MM
/
DD
/
YYYY
Do you have a fever (100 or greater) or sense of having a fever? *
Do you have COVID-19 symptoms (dry cough, sore throat, shortness of breath, loss of smell/taste)? *
Have you been tested and/or had a positive COVID-19 test in the past 14 days? *
Have you had close contact with someone suspected of or confirmed with COVID-19 in the past 14 days? *
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