Employee COVID-19 Self Screening Questionnaire

You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT enter the company’s buildings. If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps AND notify your manager and HR.


* “Close contact” is defined as living in the same house, being an intimate partner, being a caregiver, or being within 6 feet of an individual for longer than 15minutes who has COVID-19.

3) Have you had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by a reason other than possibly having COVID-19?


If personnel answered YES to any of the questions, they must be sent home and follow the isolation/quarantine steps here.


Temperature Check -- Use No-touch thermometer; Please sanitize before and after use

Alameda County Public Health Department considers anyone with a temperature of 100 degrees F (37.8 C) or higher to have a fever. Anyone with a temperature of 100 degrees F (37.8 C) or higher should be sent home.


I certify to the best of my knowledge; this information is accurate.