• MM slash DD slash YYYY
    Choose Date
  • Please enter a number from 95.0 to 104.0.
    Enter Employee's Current Body Temperature
  • In the last 24 hours, have you had a fever, chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea? IMPORTANT: A "YES" IS TO BE REPORTED TO THE PLAN ADMINISTRATOR!
  • In the last 24 hours, have you been exposed to anyone diagnosed with COVID-19? IMPORTANT: A "YES" IS TO BE REPORTED TO THE PLAN ADMINISTRATOR!