Sample Employee Health Screening
Survey for COVID-19

You can customize the questions to match your local requirements
1
Diagnose
2
Close
Contact
3
Symptoms
Diagnose

Within the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus?

1
Diagnose
2
Close Contact
3
Symptoms
Close Contact

Within the past 14 days, have you been in    close physical contact   (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?

You are a close contact of a COVID-19 positive person if, from 48 hours before their symptoms began, the person with COVID-19:
  • Lived or stayed overnight with you
  • Was your intimate sex partner *
  • Took care of you or you took care of them
  • Stayed within 6 feet of you for more than 10 minutes while they were not wearing a face mask
  • Exposed you to direct contact with their body fluids or secretions (e.g., coughed or sneezed on you) while you were not wearing a face mask, gown, and gloves

* You can edit more sensitive to questions to meet your business needs and still comply with state and local mandates.

* You can also include   travel related    questions to handle special cases such as for out of state travel or recent cruise-line trips. Just contact us for more information at support@healthyscreen.ai

1
Diagnose
2
Close Contact
3
Symptoms
Symptoms

Have you had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by a pre-existing condition?

  • Fever (100.4°F/38.0°C or greater), Chills, or Repeated Shaking/Shivering
  • Cough
  • Sore Throat
  • Shortness of Breath, Difficulty Breathing
  • Feeling Unusually Weak or Fatigued
  • Loss of Taste or Smell
  • Muscle pain
  • Headache
  • Runny or congested nose
  • Diarrhea
  • Nausea or Vomiting

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Employee after health screening
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