What does the Daily Symptom Checker look like for the Supervisor reporting on behalf of an employee

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Supervisor for employee daily symptom checker

Reported on behalf of Employee Name:
Name:
eMail:
Supervisor:
Dept: 

Instructions
Please fill in all fields, including today’s date, your temperature and any symptoms you may be experiencing. You may choose more than one symptom.

Symptoms:
Date:* MM/DD/YY
Temperature:* 98.6

In the past two weeks, have you TESTED positive for COVID-19? Or, were you living with or had close contact with someone who has TESTED positive for COVID-19? (Yes or No)

Select all NEW symptoms that you are experiencing. You do not have to select symptoms related to pre-existing conditions, other known conditions diagnosed by a doctor, such as an infection, or seasonal allergies.

  • Fever
  • Chills
  • Cough
  • Shortness of Breath / Difficulty
  • Breathing
  • Body or Muscle Aches
  • Sore Throat
  • Nausea, Vomiting or Diarrhea
  • Loss of taste or smell

Describe other symptoms:

I certify the information is true.

Submit the Form