Employee Status Checklist (COVID-19)
What does this form include?
This form contains 6 sections:
Important information
Symptoms
- Breathing difficulty
- Cough
- Fever
- Headache
- Joint pain
- Muscle aches
- Nasal discharge
- Nausea
- Skin spots
- Sore throat
Transportation
- Bicycle / scooter
- Car (owned)
- Car (shared)
- Public transportation (bus or metro)
- Taxi / transportation app
- Walking
Surroundings
- Have you been in contact with someone who has traveled abroad in the past 30 days?
- Have you been in contact with a person who tested positive for Coronavirus (COVID-19)?
- Have you been in contact with someone who has had Coronavirus symptoms (COVID-19)?
COVID-19 preventive measures
- Do you wash your hands often?
- Are you maintaining social distance (over 2 meters)?
- Change clothes when you get home and put these items to wash?
- Cover your mouth and nose when coughing and / or sneezing?
- Do you avoid touching the eyes, nose and mouth?
- Is drinking more than 2 lt. of water daily?
- Leave your shoes outside of your house?
- When you arrive at your destination, is washing your hands the first thing you do?
Employee's signature
Use this template