COVID-19 Questionnaire Sept 2020
COVID-19 QUESTIONNAIRE
Employee Name: Date: _____________________
1) Have you been tested for Covid19 in the past 28 days?
1.1 Date:
_______________________________________________
1.1 Result:
_______________________________________________
2) Since March 13, 2020 have you been required to self-isolate or
quarantine?
2.1 Date:
_______________________________________________ 2.2:
Reason:
_______________________________________________
3) Have you been in close contact with someone that has tested
positive for Covid19 or has exhibited symptoms of COVID19?
("close contact" means being less than 2 meters; for example
someone you live with or someone you have been providing
care to).
4) Have you or someone you live with, traveled outside the country
in the last 14 days?
Do you have any of the symptoms below? (Please check all that
apply).
Fever
Difficulty breathing
Cough
Loss of smell
Nausea
None of the above
Declaration
I declare the above to be true and accurate.
Signature: __________________________________________ Date: ________________
MaxSys Representative: _______________________________
