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Coronavirus 2019 (COVID-19) Health Screening Questionnaire

As part of our efforts to keep all employees, visitors, and patrons safe, we ask that you please complete the following health screening questionnaire prior to entering the premises.

Instructions: Please fill in the following information.

Instructions: Please select either YES or NO to each question below.

NOTE: If an individual answer “YES” to any of the screening questions below, the individual should not visit or report to the establishment. The individual should be advised to leave and to contact their healthcare provider for further evaluation.

Do you have any of these other symptoms today?

Coronavirus 2019 (COVID-19): Sample Health Screening Tool Last Updated: September 29, 2020