COVID-19 Health Screening Questionnaire Name* First Last Branch*Choose OneWebster Memorial Branch: DecaturAntwerp Sunshine LibraryBangor Branch LibraryBloomingdale BranchCovert BranchGobles BranchLawrence BranchHiddenDate MM slash DD slash YYYY HiddenTime : Hours Minutes AM PM Until further notice, upon entering your Library branch at the beginning of every work shift, ask yourself the questions below and take your temperature using the provided touchless thermometer.In the past 24 hours have you experienced a fever or felt feverish?* No Yes In the past 24 hours have you experienced new or worsening cough?* No Yes In the past 24 hours have you experienced shortness of breath?* No Yes In the past 24 hours have you experienced sore throat?* No Yes In the past 24 hours have you experienced muscle aches?* No Yes In the past 24 hours have you experienced severe headache?* No Yes In the past 24 hours have you experienced new loss of taste or smell?* No Yes Is your temperature 100.4°F or higher?* No Yes If you answered 'yes' to any of the symptoms listed above, or your temperature is 100.4°F or higher, please do not go into work. Contact your immediate supervisor to inform them of the situation, self-isolate at home, and contact your primary care physician’s office for direction. Do not return to work without permission from your primary care physician AND after discussing the matter with your immediate supervisor. Are you fully vaccinated against COVID-19?*Being fully vaccinated is defined as two weeks having passed after having received the final injection of either a two dose COVID-19 vaccination, such as those manufactured by Pfizer or Moderna, or a single dose COVID-19 vaccination such, as the one manufactured by Johnson & Johnson. No Yes In the past fourteen 14 days, have you had close contact with an individual diagnosed with COVID-19?*Close contact is now defined by the CDC as coming within less than six feet, for a cumulative total of 15 minutes or more, over a 24-hour period, starting from two days before illness onset or, for asymptomatic individuals, two days prior to test specimen collection, until the time the patient is isolated. No Yes In the past fourteen 14 days, have you travelled internationally?* No Yes If you answered “yes” to either of these questions, please do not go into work, and please inform your immediate supervisor of the situation so the appropriate health measures may be taken.CAPTCHA
