Employee Daily Self Health Monitoring Form

All employees should monitor their own health on a daily basis. We have created the following health monitoring form for employees to review each day before returning to work. Click here to download the form, which is for employee use only and not to be submitted.

EMPLOYEE DAILY SELF HEALTH MONITORING FORM

SYMPTOMS – answer yes or no to each – every day NO YES
Have you felt sick or feverish in the past 24 hours?
Have you had any of these symptoms in the past 24 hours?

  • New cough
  • Sore throat
  • Short of breath or trouble breathing
  • Headache
  • New body aches or muscle pain
  • New loss of taste or smell
Have you had any of these symptoms in the past 24 hours not related to allergies? 

  • Runny nose
  • Stuffy nose
  • Sneezing
If you have had runny nose, stuffy nose, sneezing in the past 24 hours, is it getting worse?
EXPOSURES – check yes or no
Have you traveled outside the state in the past 14 days?
Have you been in close contact with someone with a confirmed or suspected case of COVID-19 in the past 14 days? 
Have you been diagnosed with COVID-19?
What to do next Answered NO to all Answered YES to anything
Report to work. Contact your healthcare provider or Faculty/Staff Wellness at 336.278.5569.

 

Apps for Monitoring Symptoms