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Health Screening
Daily COVID-19 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.
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