What does the Employee Daily Symptom Checker look like?

Estimated reading time: < 1 min

Here is a sample image of the online form.

Employee Daily Symptom Checker

Self-Reported Information:
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
Best Contact Phone Number:*

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.