Health Screening

Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Are you feeling Sick? (e.g. Sore throat, cough, shortness of breath or difficulty breathing, vomiting/diarrhea)*
- Yes
- No
In the past 72 hours have you had a fever?*
- Yes
- No
Have you been exposed to anyone who is a suspected case or who has*
- Yes
- No
By checking this box I am electronically signing my Health Screening.*
- Sign Here
Section Break
Any employee or worker entering a Township Office who answers “yes” any of these questions shall be sent home and may not return to work until the provisions of Section 4, "Sick Employees Returning to Work" of the Township's Preparedness Plan are satisfied.

Bessemer Township