COVID-19 Screening Form
Who is your Employer?
*
please make a selection
Delta Hotel
The Lake House Waterfront Grille
Shoreline Inn
Delta F&B
Vendors
Employee Name:
*
Email Address
*
Date
*
MM slash DD slash YYYY
Time In:
*
:
Hours
Minutes
AM
PM
AM/PM
In the past 24 hours, have you experienced:
Fever (felt feverish or had temperature above 100.4° F)
*
Yes
No
New or Worsening Cough
*
Yes
No
Shortness of Breath
*
Yes
No
Sore Throat
*
Yes
No
Vomiting/Diarrhea
*
Yes
No
Been directed by a health department or healthcare provider to self-isolate or self-quarantine?
*
Yes
No
If you answer
“Yes”
to any of the symptoms listed above, or your temperature is 100.4° F or higher, avoid contact with other employees and contact your supervisor immediately.
CAPTCHA