Employee Screening Questionnaire Date* MM slash DD slash YYYY Name First Last 1. Do you have a fever of 100.4 degrees or higher (as measured by a touchless thermometer if available, but verbal confirmation is sufficient)?* Yes No 2. Today’s Temperature:* 3. Have you experienced a cough, sore throat and/or had difficulty breathing in the past 14 days?* Yes No 4. Are you experiencing shortness of breath?* Yes No 5. Do you have at least 2 of the following symptoms: chills, repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, diarrhea (excluding diarrhea due to known medical reason), and/or extreme fatigue?* Yes No 6. Have you had any close contact in the last 14 days with someone with a diagnosis of COVID-19?* Yes No 7. Have you traveled internationally or outside of Michigan in the last 14 days, excluding commuting from a home location outside of Michigan? (commuting is defined as traveling between one’s home and work on a regular basis)* Yes No Signature*
