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...
- Newly experienced any of the following symptoms that cannot otherwise be attributed to another condition?
- Fever (100.0 F or higher)
- Loss of taste or smell
- Shortness of breath or difficulty breathing
- Sore throat
- Muscle pain or aches
- Nausea, vomiting or diarrhea
- Runny nose or congestion
- Tested positive for, or have been diagnosed by a healthcare provider, with COVID-19 within the past 10 days?
- Been advised by a healthcare provider or a public health agency to self-quarantine within the last 14 days?
- Had close contact with someone experiencing symptoms, or someone with known exposure to COVID-19?
- 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?
- 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.