Covid Screening Form

Enter your name and answer the questions using the form below.

When complete you will be shown a screen to present to the screeners when you arrive for your shift.
NOTE: This form must be completed prior to each shift.

First Name

Last Name

Which hospital are you screening for?

TDMH

Do you have any of the following symptoms?

Fever, sore throat, difficulty swallowing, runny nose, chills, headache (without known cause), nasal congestion (without known cause), new onset of cough, worsening chronic cough, difficulty breathing, unexplained fatigue, muscle aches, diarrhea, abdominal pain, nausea, vomiting, pink eye (conjunctivitis) or decreased/loss of smell / taste.

Yes

Have you tested positive for COVID-19, or have you been in close contact with a confirmed case or probable case of COVID-19 without wearing appropriate PPE?

Yes

If yes to ANY of the above, have you been in contact with Occupational Health/ Leadership and approved to be at work with appropriate precautions.

N/A

Yes