COVID-19 Health Screening Questionnaire Name* First Last Branch*Choose OneWebster Memorial Branch: DecaturAntwerp Sunshine LibraryBangor Branch LibraryBloomingdale BranchCovert BranchGobles BranchLawrence BranchDate Date Format: MM slash DD slash YYYY Time : HH MM 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?*NoYesIn the past 24 hours have you experienced new or worsening cough?*NoYesIn the past 24 hours have you experienced shortness of breath?*NoYesIn the past 24 hours have you experienced sore throat?*NoYesIn the past 24 hours have you experienced diarrhea?*NoYesIn the past 24 hours have you experienced muscle aches?*NoYesIn the past 24 hours have you experienced vomiting?*NoYesIn the past 24 hours have you experienced abdominal pain?*NoYesIn the past 24 hours have you experienced severe headache?*NoYesIn the past 24 hours have you experienced new loss of taste or smell?*NoYesIs your temperature 100.4°F or higher?*NoYesIf 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. 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.NoYesIn the past fourteen 14 days, have you travelled internationally?*NoYesIf 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
