Covid Health Check Form

Covid Health Check Form

Complete this form in full BEFORE reporting to work.

Location
City Hall
Police
Engineering
Public Works
Marina
Activity Center
Beach Park

Employee Name

Do you have a temperature today that registers at or above 100.4?

Yes
No

Have you in the past 24 hours experienced any of the following symptoms; subjective fever (felt feverish), new or worsening cough, shortness of breath, sore throat?

Yes
No

If you answer "yes" to any of the symptoms listed above, or your temperature is 100.4 F or higher, notify your manager. Self-isolate at home and contact your healthcare provider for advice. * You should isolate at home for a minimum of 7 days since symptoms first appeared. * You must also have 3 days without fevers and improvement in respiratory symptoms.

In the past 14 days have you:

Had close contact with an individual diagnosed with COVID-19?

Yes
No

Traveled via airplane internationally or domestically (unless exempt)?

Yes
No
 

For questions, consult your healthcare provider or local health department.
Contact information for King the County Health Department or call 206-477-3977.