COVID-19 Employee Health Screening Questionnaire

Dear Employee,

In accordance with the CDC, NYS Dept. of Health and Governor Cuomo’s directives on reopening New York State; all employees are required to check their temperature and complete a health screening questionnaire prior to coming into work each day. Upon arrival at work you must submit the completed health screening questionnaire to your supervisor/manager. Your supervisor/manager will review the questionnaire to assess your work status.

If you have a temperature of 100 or higher and/or answer yes to any of the questions below, you will not be allowed to work until cleared by Revere’s Occupational Health Nurse (OHN).

Your supervisor/manager will forward all completed employee health screening questionnaires to Revere’s Occupational Health Nurse and they will be maintained in the employee health office.

Thank you,
Karen Arbogast RN, OHN

Employee ID Adjusted Service Date