NTN Covid19 Employee Questionnaire - National Training Network

Employee Name *

Date *

Please Record Your Temprature *

Have you experienced a fever of 100.4 degrees Fahrenheit or greater, a new cough, new loss of taste or smell, shortness of breath within the past 5 days?

No
Yes

In the past 5 days, have you tested positive for COVID-19 using a test that tested saliva or used a nose or throat swab (not a blood test)? (5 days measured from the date you were tested, not the date you received the test result.)

No
Yes

To the best of your knowledge, in the past 14 days, have been in close contact (within 6 feet for at least 10 minutes) with anyone while they had COVID-19?

No
Yes

Have you been tested for COVID-19 and are awaiting the results?

No
Yes

NOTICE

No further screening is needed. You may not report to the workplace.

Please wear a mask and social distance. You should get tested 5 days from the potential exposure.

You may not report to the workplace, until 5 days have passed from testing positive.

If you answered yes to Questions 2 or 4, please note that after 5 days and you no longer have a fever, you can report to work masked with social distancing.

NTN Employee Health Screening for COVID-19

NOTICE