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Updated Employee Self-Assessment Questions

To help protect ourselves, our families and the residents from potential exposure to the Covid-19 virus, you must complete this survey daily prior to reporting to work.


*This form has been updated as of 6/10/21.  Please read through carefully. * 


In the past 14 days have you or anyone in your household had contact with anyone who:

  • Has been diagnosed by a laboratory or physician as COVID-19 positive; or
  • Is subject to a Federal, State or Local quarantine or isolation order related to COVID-19; or
  • Has been advised by a health care provider to quarantine related to COVID-19

Choose One

Have you knowingly been in close contact (within 6 feet for more than 10 minutes) with someone who has tested positive for COVID-19 in the last 14 days?

Choose One

Have you experienced one or more of the following symptoms in the past 48 hours? 

  • fever or chills
  • cough
  • shortness of breath or difficulty breathing
  • fatigue
  • muscle or body aches
  • headache
  • new loss of taste or smell
  • sore throat
  • congestion or runny nose
  • nausea or vomiting
  • diarrhea

Choose One

Do you currently have a fever of 100.4 degrees Fahrenheit or higher? (without fever reducing medication)

Choose One

Are you UNVACCINATED and have traveled internationally or to States other than NJ, NY, DE, CT or PA, in the last 7 days?

Choose One

What is your current temperature taken from the Thermal Scanner?

After completing and submitting this form any employee answering yes to any of the above listed questions must immediately notify their Supervisor/Department Head and will not be permitted to return to work without written medical clearance from a health care provider.

Forms will be housed in employee’s confidential medical file.

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