Daily Health Questionnaire

A quick daily questionnaire for staff to report body temperature, possible symptoms, and any risky contacts before entering the workplace.

Use this template

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1. Check the box below if you have any of the following.

2. Body temperature upon coming in the office.

& leaving

3. List of places you have been and full name of persons you have contact with/encountered from the time you left the office up to the time you have arrived back the next morning.

4. Did anyone you have contact with have any signs of cough or fever? If yes, kindly indicate his/her full name and a description of the interaction.

5. Check the boxes below if you have followed today and yesterday the following safety precautions to avoid the virus.

Wearing a mask Frequent hand washing Social distancing Disinfecting surfaces

I certify that the information above is true and complete.

Printed Name

Date

Reviewed and approved by:

Jerry Marte/Carlos Critica

Date

Keep a copy of this form for your records.

Daily Health Questionnaire

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