Name*

Review this COVID-19 Daily Self Checklist each day before reporting to work. If you reply YES to any of the questions below, STAY HOME (with pay) and follow the steps below:

Step 1: Call Jeff or Phil and follow-up with an email
Step 2: If you start feeling sick during your shift, follow steps 1 and 2 above.

Do you have a fever (temperature over 100.30F) without having taken any fever reducing medications?*

Yes
No

Sore Throat*

Yes
No

Shortness of Breath?*

Yes
No

Loss of Smell or Taste?*

Yes
No

Muscle Aches?*

Yes
No

Chills?*

Yes
No

Cough?*

Yes
No

Headache?*

Yes
No

Have you experienced any gastrointestinal symptoms such as nausea/vomiting, diarrhea, loss of appetite?*

Yes
No

Have you, or anyone you have been in close contact with been diagnosed with COVID-19, or been placed on quarantine for possible contact with COVID-19?*

Yes
No

Have you been asked to self-isolate or quarantine by a medical professional or a local public health official?*

Yes
No

Covid 19 self-checker

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