Sample COVID-19 Health Screening Questionnaire
Date: _________________________________________________________________________
Name: ________________________________________________________________________
Department: ___________________________________________________________________
The purpose of this screening tool is to minimize workplace transmission of COVID-19 by identifying employees’
potential exposures and responding with appropriate measures, which may include, for example, focused follow-
up questions, working from home, temporary leave from the workplace, testing and/or fit-for-duty certification.
To assist with these measures, the New Hampshire Bureau of Infectious Disease Control has developed an Isolation
and Quarantine Summary for employers, which may serve as a situational assessment tool, at page four of the
following (effective August 27, 2020): https://www.dhhs.nh.gov/dphs/cdcs/covid19/documents/employee-
travel-guidance.pdf
YES NO
1. I have one or more flu-like symptoms that I do not normally experience in connection
with a pre-existing health condition, and which are causing me to feel unwell. Such
symptoms may include, but are not necessarily limited to, unusual headache, fatigue,
runny nose, muscle aches, sore throat, cough, fever, shortness of breath, change in
sense of taste or smell, and chills.
2. A person residing or staying in my household has one or more symptoms described in
#1 causing them to feel unwell.
3. I answered no to #1 and #2, but I, or someone residing or staying in my household, did
have symptoms within the last 72 hours.
4. I have had contact with an individual who has tested positive for COVID-19 within the
last 14 calendar days.
5. I have had contact with an individual who is experiencing flu symptoms such as those
indicated in #1, but has not been tested for COVID-19 within the last 14 calendar days.
6. In the past 10 days, have you traveled internationally (outside of the U.S., except for
essential travel to/from Canada) or on a cruise ship?
7. Do you have a fever (over 100 degrees) or are you feeling feverish?
This form is a guidance document provided as a sample. Use of the form is not required by Primex
s
in connection
with membership, coverage or services. The implementation of workplace screening is a local policy decision that
should be based on consideration of current executive orders, public health guidelines and operational needs. The
form may be modified; however, we would strongly recommend adherence to any applicable executive orders and
public health guidelines. This is a general form. Certain occupations may be subject to different screening inquiries
and procedures. To that point, for example, questions 4 and 5 may focus more appropriately on “unprotected
contact” for public safety workers using PPE.
rev. 3/19/2021
