COVID-19 Daily Health Screening Form

A quick daily self-check that employees, students, or visitors complete to report symptoms and risk factors before entering a facility.

Use this template

Already have an account? Log in

Name

First Name

Last Name

Date:

Time:

Screening Employee

First Name

Last Name

Fever within the past 24 hours?

Yes No

Coughing/Sneezing?

Yes No

Sore throat?

Yes No

Shortness of breath?

Yes No

Recent travel to high risk areas?

Yes No

Contact with people infected, or diagnosed with COVID-19?

Yes No

Resides in a community where community-based spread of COVID-19 is occurring?

Yes No

Additional Comments

Related templates

3 Day Diet Diary Form Healthcare 360 Assessment Report Preparation Form Human Resources 4D Lifestyle Assessment Form Assessments 4-Point Inspection Form Insurance

Powerful online forms — builder, logic, products, and teams — at a price that makes sense.

Rejoining the server...

Rejoin failed... trying again in seconds.

Failed to rejoin.
Please retry or reload the page.

The session has been paused by the server.

Failed to resume the session.
Please retry or reload the page.