"Employee Screening Form" - Alabama

Employee Screening Form is a legal document that was released by the Alabama Department of Mental Health - a government authority operating within Alabama.

Form Details:

  • Released on June 30, 2020;
  • The latest edition currently provided by the Alabama Department of Mental Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Alabama Department of Mental Health.

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EMPLOYEE SCREENING FORM
THIS FORM IS TO BE COMPLETED AND SUBMITTED PRIOR TO REPORTING TO THE OFFICE EACH DAY
Leave will be utilized in accordance with normal policies and procedures.
Employee Name: ________________________
Date: ________________________
My current temperature is _________________
Is your temperature 100.3 or higher?
___yes
____no
Do you have a cough with shortness of breath?
___yes* ____no
Do you have body aches?
___yes
____no
Have you been in close contact for an extended period of time with anyone who has been diagnosed
with the COVID-19 virus?
___yes ____no
(Close contact is, 15 minutes or longer in a closed area in which a 6-foot distance was not maintained
from the diagnosed individual.)
If you answered yes to any one of these questions regarding symptoms, contact your supervisor. Do
not report to the office. *If you have a chronic condition that causes similar symptoms without fever
and is not infectious, such as allergies or sinus issues, discuss this with your supervisor. Employees and
PROTOCOLS FOR
Supervisors refer to Employees Who Are Experiencing Symptoms in the attached
EMPLOYEES AND SUPERVISORS
for next steps.
If you answered yes to having close contact with a person diagnosed with COVID-19, Employees and
Supervisors refer to Employees Who Have Been In Close Contact With Someone With A Covid-19
Diagnosis in the attached
PROTOCOLS FOR EMPLOYEES AND SUPERVISORS
for next steps.
If you answered no to all of these questions, you should report to work and adhere to the following
guidelines:
You are expected to wear a face covering in common areas such as hallways, break rooms, rest
rooms, conference rooms, etc., and during any face-to-face contact with others.
Keep 6 feet of distance between you and others at all times.
Please immediately wash your hands or use hand sanitizer upon entering and leaving this
building and touching common surfaces (door handles, packages, etc.).
Please be mindful to cough or sneeze into a tissue or the corner of your elbow and to wash your
hands often while here.
Avoid using other employees’ phone, computer and other work tools.
Employees will need to clean and disinfect frequently used items at the beginning and end of
the day.
By forwarding this email to your supervisor, you certify that your answers above are true and that you
will comply with the instructions provided.
Employees exhibiting symptoms may be subject to temperature checks while at work.
June 30, 2020
EMPLOYEE SCREENING FORM
THIS FORM IS TO BE COMPLETED AND SUBMITTED PRIOR TO REPORTING TO THE OFFICE EACH DAY
Leave will be utilized in accordance with normal policies and procedures.
Employee Name: ________________________
Date: ________________________
My current temperature is _________________
Is your temperature 100.3 or higher?
___yes
____no
Do you have a cough with shortness of breath?
___yes* ____no
Do you have body aches?
___yes
____no
Have you been in close contact for an extended period of time with anyone who has been diagnosed
with the COVID-19 virus?
___yes ____no
(Close contact is, 15 minutes or longer in a closed area in which a 6-foot distance was not maintained
from the diagnosed individual.)
If you answered yes to any one of these questions regarding symptoms, contact your supervisor. Do
not report to the office. *If you have a chronic condition that causes similar symptoms without fever
and is not infectious, such as allergies or sinus issues, discuss this with your supervisor. Employees and
PROTOCOLS FOR
Supervisors refer to Employees Who Are Experiencing Symptoms in the attached
EMPLOYEES AND SUPERVISORS
for next steps.
If you answered yes to having close contact with a person diagnosed with COVID-19, Employees and
Supervisors refer to Employees Who Have Been In Close Contact With Someone With A Covid-19
Diagnosis in the attached
PROTOCOLS FOR EMPLOYEES AND SUPERVISORS
for next steps.
If you answered no to all of these questions, you should report to work and adhere to the following
guidelines:
You are expected to wear a face covering in common areas such as hallways, break rooms, rest
rooms, conference rooms, etc., and during any face-to-face contact with others.
Keep 6 feet of distance between you and others at all times.
Please immediately wash your hands or use hand sanitizer upon entering and leaving this
building and touching common surfaces (door handles, packages, etc.).
Please be mindful to cough or sneeze into a tissue or the corner of your elbow and to wash your
hands often while here.
Avoid using other employees’ phone, computer and other work tools.
Employees will need to clean and disinfect frequently used items at the beginning and end of
the day.
By forwarding this email to your supervisor, you certify that your answers above are true and that you
will comply with the instructions provided.
Employees exhibiting symptoms may be subject to temperature checks while at work.
June 30, 2020