Fillable Texas Department of Criminal Justice (Texas Tech University-Health Sciences Center)

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Texas Department of Criminal Justice (Texas Tech University-Health Sciences Center)

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Texas Department of Criminal Justice
COVID-19 Health Screening Form
April 4, 2020
Before any individual enters a TDCJ location, they will have their temperature taken and if a fever is present, the
screening form must be completed. This health screening form is an important first step to assist staff in
maintaining the safety and health of TDCJ employees and offenders.
Clearly PRINT information below:
Name:
Birthdate (mm / dd):
Has the individual:
Date Range
Traveled internationally in the
last 30 days?
Yes No
If yes when?
*Had close contact with
anyone who tested positive for
COVID-19 in the last 14 days?
Yes
No
If yes when?
Does the individual have:
Result
Fever above 100.4F?
Yes No
If yes, temperature?
Cough?
Yes No
Shortness of breath?
Yes No
If the individual answers yes to fever question, they will be sent home and will be required to submit a physician’s
note stating they are clear of COVID-19 symptoms before being allowed to return to work. If no fever is present
but answered yes to cough or shortness of breath, the individual should be aware of potentially developing a fever.
*If the individual answers yes to being in close contact with anyone who tested positive for COVID-19, they will
be sent home for a period of time, which will be determined by the supervisor. If the employee develops symptoms
while off work, it is imperative they contact their supervisor and keep them informed. The employee will be able
to return to work by providing a physician’s note stating they are clear of any COVID-19 symptoms. If the
employee did not develop symptoms while off work, then a physician’s note is not required. Notification will need
to be made to the Melissa Kimbrough, Office of Emergency Management and Chris Black Edwards, Deputy
Director Health Services and Shannon Wood, Employee Services.
Staff completing COVID-19 Health Screening Form:
Name:
Date: ______________________________
CONTACT INFORMATION:
Melissa Kimbrough, Emergency Management Coordinator Chris Black-Edwards, Deputy Director Health Services
936-581-9848 (State Cell) 936-437-4001 (Office)
melissa.kimbrough@tdcj.texas.gov chris.black-edwards@tdcj.texas.gov
Shannon Wood, Manager Employee Services
936-661-3844 (State Cell)
shannon.wood@tdcj.texas.gov
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Texas Department of Criminal Justice (Texas Tech University-Health Sciences Center)

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Completed 28 August 2020

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