C19 Health Screening

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COVID-19 HEALTH SELF SCREENING

* Indicates required field

Select Reason for Visit *

Employee/Member Student Vendor Visitor

Station *

Email *

Name *

First

Last

Have you had a fever in the last 24 hours, either measured or felt like you had a fever? *

YES - Do not enter NO - Cleared to continue

Have you had a cough, particularly a dry cough, in the last 72 hours? *

YES - Do not enter NO - Cleared to continue

Have you experienced shortness of breath that is abnormal for you, whether at ret or with physcial activity in the past 72 hours? *

YES - Do not enter NO - Cleared to continue

Have you been exposed to a confirmed case of COVID-19 without having worn proper PPE as defined previously as at a minimum an N95? *

YES - Refer to supervisor, and wear mask at all times on premises for 10 days post exposure NO - Cleared to move forward

Using the supplied thermometer, follow instructions at site to take tempurture, and record below. IF ABOVE 100.3 degrees, you are NOT CLEARED to enter *

CLEARED? If any item above is marked YES, or your temp is above 100.3 *

CLEARED - OK to enter NOT CLEARED - DO NOT ENTER

Submit

Proudly Serving the Town of Clinton, Clinton Township, Lebanon Borough, High Bridge Borough, Hampton Borough, Glen Gardner Borough and portions of Franklin, Bethlehem and Union Townships since 1953

Home
About
Training
- Course Evaluation
- EMT >
- FFCPR
- Fit Testing
News
Join Us
Member Zone
- Member Discount Programs
Contact
DONATE
- CoinToss
- Raffle
Lobster
- 25 Lobster Sponsor
- 25 Lobster Tickets