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SURVEY
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COVID-19 Screening Questionnaire
Screen staff, visitors, or attendees for COVID-19 symptoms and exposure before entry.
Log in to use this template
Preview — how respondents will see this form
Full Name
*
Short answer…
Date of Screening
*
Select date…
Have you tested positive for COVID-19 in the last 10 days?
*
Yes
No
Are you experiencing any of the following symptoms today?
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
Sore throat
Fatigue
None of the above
Have you been in close contact with a confirmed COVID-19 case in the last 14 days?
*
Yes
No
Have you travelled internationally in the last 14 days?
Yes
No
Additional notes (optional)
Long answer…