Staff Screening Checklist

If YES to any, the employee is not permitted to enter the facility and must go home and notify their supervisor.
If proceeding onsite, the individual must remember to:
• Wash or sanitize their hands using an alcohol-based hand sanitizer at least every 60 minutes
• Not shake hands with or touch individuals
• Stay in their assigned work area as much as possible
• Use only the designated bathroom for their department
• Wear their mask at all times, except during lunch breaks
• Maintain social distancing, at least 6 feet, as much as possible.

Signature(Required)

I have read the requirements to enter the building and attest that by signing this form I am in compliance with noted requirements.