COVID-19 Daily Questionnaire

Please submit this form daily when reporting to work.

Enter your name, temperature, and check any boxes that apply.

Your Name  

Your Temperature  

Do you have a cough?

Do you have a fever now or within the past 14-21 days?

Have you come in contact with any COVID-19 positive person in the past 14 days?

Are you experiencing shortness of breath or difficulty breathing?

Are you experiencing flu-like symptoms such as gastrointestinal upset, headache, or fatigue?

Have you experienced recent loss of taste or smell?

Have you traveled in the past 14 days to any region outside of Michigan?

Notes Optionally enter any additional notes or an explanation if you have checked any boxes above.