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Please fill out the COVID 19 Screening Checklist
Full name of the individual
Has the individual washed their hands or used antiseptic?
No (please ask them to do so)
Does the individual have any of the following symptoms? Check all that apply.
Shortness of Breath
Persistent Pain in the Chest
Is this person an employee?
Please check their temperature and enter the result.
Has the individual been in contact with someone that was infected, suspected, or diagnosed with COVID-19? *
Thank you for filling out the information.
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