Irlen Screening & Diagnostic
Insurance & Doctors
COVID Health Screener
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Employee COVID-19 Questionnaire and Health Screening Form
Prior to your shift
Please complete this form prior to your scheduled shift.
Do you or anyone living in your household currently have any of the following symptoms:
Fever (temperature over 99.5)
Cough/ shortness of breath
Loss of taste/ smell
Is anyone in your household currently under quarantine for a covid 19 related exposure or diagnosis?
I acknowedge that the information I have provided is accurate and up to date.
I accept terms & conditions