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2. Coronavirus Disease (COVID-19) Workplace Health Screening.
   Please complete this brief health screening questionnaire before coming into the workplace.
4. Department Name*
6. Employee Name*
7. Date and Time*
   Date and Time

   Date and Time
9. If you answer “yes” to any of the symptoms listed below, or your temperature is 100.4°F or higher, please do not go to into work. Inform your supervisor and self-isolate at home. You must consult with the health department and they will need to provide clearance for your return to work. •You should isolate at home for a minimum of 5 days since symptoms first appear; and • 24 hours have passed since the resolution of fever without the use of fever-reducing medications; AND •other symptoms are improving . •Continue to wear a mask around others for 5 additional days.
11. IN THE PAST 24 HOURS, HAVE YOU EXPERIENCED:
13. Fever or Chills:*

    1. Yes
    2. No
14. Cough:*

    1. Yes
    2. No
15. Shortness of breath/difficulty breathing:*

    1. Yes
    2. No
16. Fatigue:*

    1. Yes
    2. No
18. Muscle or body aches:*

    1. Yes
    2. No
19. Headache:*

    1. Yes
    2. No
20. New loss of taste or smell:*

    1. Yes
    2. No
21. Sore throat:*

    1. Yes
    2. No
23. Congestion or runny nose:*

    1. Yes
    2. No
24. Nausea or vomiting:*

    1. Yes
    2. No
25. Diarrhea:*

    1. Yes
    2. No
27. Current Temperature (if known)
29. You answered “yes” to one of the symptoms listed and/or or your temperature is 100.4°F or higher. *

    1. I understand

    Please do not go into work. Inform your Supervisor and self-isolate at home. You must consult with the health department and they will need to provide clearance for your return to work.

    •You should isolate at home for a minimum of 5 days since symptoms first appear; AND .

    •24 days have passed since the resolution of fever without the use of fever-reducing medications; AND

    •Other symptoms are improving.

    •Continue to wear a mask around others for 5 additional days.

    
    

31. IN THE PAST 5 DAYS, HAVE YOU:
33. If you answer “yes” to either of these questions, you should follow the most recent CDC guidance on quarantining/isolating.
35. Had close contact with an individual diagnosed with COVID-19?*

    1. Yes
    2. No
36. Traveled internationally or taken a cruise?*

    1. Yes
    2. No
38. For Questions
    https://www.mmdhd.org

    Visit the website (link above) or contact Mid-Michigan District Health Department at Clinton County: 989-224-2195, in Gratiot County: 989-875-3681 and in Montcalm County: 989-831-5237.
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