Employee Name:

Job Title:

Supervisor:

________________________________________

________________________________________

________________________________________ Date: ____________________

Body Temperature below 100.4 degrees Fahrenheit
	Traveled out of state in the last 14 days? (Does not apply to people who travel across state lines as part of normal work activity)
	
Respiratory Symptoms in the last 14 days (e.g. cough, difficulty breathing, fever)
	
Exposure to a person diagnosed with COVID 19 in the last 14 days

YES

NO

YES

NO

YES

NO

YES

UNKNOWN

Body Temperature taken by ESC guard if employee did not take temperature at home? ______________

YOU MUST WEAR A MASK WHEN ENTERING THE BUILDING AND IN ALL COMMON AREAS OF THE BUILDING.

Employee Name:

Job Title:

Supervisor:

________________________________________

________________________________________

________________________________________ Date: ____________________

Body Temperature below 100.4 degrees Fahrenheit
	Traveled out of state in the last 14 days? (Does not apply to people who travel across state lines as part of normal work activity)
	
Respiratory Symptoms in the last 14 days (e.g. cough, difficulty breathing, fever)
	
Exposure to a person diagnosed with COVID 19 in the last 14 days

YES

NO

YES

NO

YES

NO

YES

UNKNOWN

Body Temperature taken by ESC guard if employee did not take temperature at home? ______________

YOU MUST WEAR A MASK WHEN ENTERING THE BUILDING AND IN ALL COMMON AREAS OF THE BUILDING.