Temperature and Health Check Self-Screening Form

KEMI requires employees working on-site and approved vendors and visitors to complete a health self-screening at home and within one hour prior to arrival at the facility, at least every 24 hours, with the employee, vendor or visitor answering each of the following questions truthfully with a Yes/No response.

Name *

First

Last

Email *

Phone *

Self-Screening Date *

Have you had any of the CDC-recognized COVID-19 symptoms since your last day at work or the last time you were here?

Fever (above 100.4°)? *

Yes
No

Cough? *

Yes
No

Shortness of breath or difficulty breathing? *

Yes
No

Sore throat? *

Yes
No

Muscle or body aches? *

Yes
No

Gastrointestinal symptoms like nausea, vomiting, or diarrhea? *

Yes
No

Chills? *

Yes
No

A new loss of taste or smell? *

Yes
No

Fatigue? *

Yes
No

Headache? *

Yes
No

Congestion or runny nose? *

Yes
No

Is there anyone in your household who is showing COVID-19 symptoms or who has been diagnosed with COVID-19? *

Yes
No

Have you been in close contact with anyone exhibiting sign or symptoms of fever, persistent cough or shortness of breath consistent with COVID-19 who has not been tested or is still awaiting testing? *

Yes
No