COVID-19 QUESTIONNAIRE

Please fill out form daily.

PLEASE ENTER YOUR EMAIL ADDRESSS BEFORE SUBMITTING FORM.

Email Address

Location:

Role in Company:

HAVE YOU OR ANYONE YOU ARE IN CLOSE CONTACT WITH...

Been Diagnosed with COVID-19 or told by a health care provider that you might have or have COVID-19?

Come in close contact (within 6ft for over 15 minutes or lived with) a Person with COVID-19 in the past 14 days?

ARE YOU/THEY CURRENTLY EXPERIENCING ANY OF THE FOLLOWING SYMPTOMS?

Fever (Greater than 100.3 F/39.0c)

Loss of Smell

Loss of Taste

Severe Headache

Sore Throat

Cough / Chills

Congestion or runny nose

Muscle/body aches / Weakness / Persistent Pain / Pressure in Chest

Diarrhea / Vomiting / Abdominal

Respiratory Symptoms / Shortness of breath / difficulty breathing

Confusion / Inability to wake or stay awake

Bluish lips or face

First Name

Last Name

Today's Date

Time

Temperature

Clinical Staff Notification Required?

I Accept that all the information above is accurate to the best of my knowledge and will be used by Superior.

Please Note: By completing this form, you agree to release your information to Superior Hospice & Superior Home Health. Your privacy is very important to us. All information submitted through this form is secured and viewed ONLY by our staff. Read our privacy policy for more info.

Safety is our number one priority

If you answered yes to any of these questions or you're experiencing mild or severe symptoms please contact management before commencing work day.

Thank you for working with us to ensure we get through this pandemic as safely as we can. We truly appreciate everyone’s patience and understanding as we try to continue our daily operations.