COVID-19 Emergency Temporary Standard Questionaire 

Please read each question carefully and circle the answer that applies. No health information or questionnaire answers will be shared with anyone outside of your organization.

Have you experienced any of the following symptoms of COVID-19 within the last 48 hours?

Fever or Chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore Throat
Congestion or Runny nose
Nausea or vomiting
Diarrhea
Have you tested positive for Covid-19 in the past 10 days?
Are you currently awaiting results from a COVID-19 test?
Have you been diagnosed with COVID-19 by a licensed healthcare provider (for example, a doctor, nurse, pharmacist, or other) in the past 10 days?
Have you been told that you are suspected to have COVID-19 by a licensed healthcare provider in the past 10 days?

Daily monitoring for potential COVID-19 symptoms is important to track your current health status. If you experience new symptoms, consider seeing your healthcare provider or getting a test for COVID-19, especially where you may have had potential exposures to COVID-19.


You should also monitor your health and consider consulting your primary care physician after testing positive for COVID-19.

You MUST inform your supervisor if you:

  • Receive a confirmed positive COVID-19 test result;
  • Have been diagnosed with COVID-19 by a licensed healthcare provider;
  • Have been told you are suspected to have COVID-19 by a licensed healthcare provider;
  • Experience new loss of taste and/or smell with no other explanation; or
  • Experience both fever (≥100.4° F) and new unexplained cough associated with shortness of breath
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