Stop COVID-19 - Employee Screening

Employee COVID-19 Screening Questionnaire

To reduce the risk of spread of COVID-19 in the workplace, employees should be screened prior to entering work. Employees can self-screen in advance of work and on site.

PRIOR TO COMING TO WORK TODAY, HAVE YOU...

1. Newly experienced any of the following symptoms that cannot otherwise be attributed to another condition?
   1. Fever (100.0 F or higher)
   2. Loss of taste or smell
   3. Shortness of breath or difficulty breathing
   4. Headache
   5. Cough
   6. Sore throat
   7. Chills
   8. Fatigue
   9. Muscle pain or aches
   10. Nausea, vomiting or diarrhea
   11. Runny nose or congestion
2. Tested positive for, or have been diagnosed by a healthcare provider, with COVID-19 within the past 10 days?
3. Been advised by a healthcare provider or a public health agency to self-quarantine within the last 14 days?
4. Had close contact with someone experiencing symptoms, or someone with known exposure to COVID-19?
5. Been tested and are awaiting results after experiencing symptoms of COVID-19 or have been in close contact with someone positive for COVID-19 or who was experiencing symptoms?
6. Traveled outside of Massachusetts without quarantining for 14 days and/or received a negative COVID-19 test result?

If you answered yes to any of the above, do not come into work. Notify your supervisor and/or HR.

Employers should not require a COVID-19 test result or a healthcare provider’s note for employees who are sick to validate their illness, qualify for sick leave, or to return to work.