Daily Health Questionnaire
Fill out and submit each morning before coming to work.
In the past 24 hours, have you had a sore throat?
Yes
No
In the past 24 hours, have you had congestion or runny nose (not allergy-related)?
Yes
No
In the past 24 hours, have you had a fever or chills?
Yes
No
Is your
CURRENT
temperature equal to or greater than 100.4 degrees Fahrenheit?
Yes
No
In the past 24 hours, have you had a new loss of taste or smell?
Yes
No
In the past 24 hours, have you been known to have or suspected to have contact with a COVID-19 patient(s)?
Yes
No
If Yes, to any of the above, please explain.
I acknowledge that the information I have provided is accurate to the best of my knowledge and complies with the safety protocols provided by the Office of the New Jersey Governor and/or the CDC.
Yes
No - check this box and contact my Supervisor immediately.
Send me a copy of my responses.
Submit
Well Done!
Your health questionnaire has been submitted.