Health Screening Form
Health Screening Form
This form is to be completed before entering
and
after leaving all Life Link III locations.
Name
Name
*
First
Last
Life Link III
Employee Number
Maximum of
4
digits allowed.
Currently Entered:
0
digits.
Date
Date
*
/
MM
/
DD
YYYY
Time
Time
:
HH
MM
Check in/out:
*
Check-In
Check-Out
Vaccine Information
Have you received a dose of any COVID-19 vaccine?
Have you received a dose of any COVID-19 vaccine?
Yes, first dose
Yes, both doses
No
Date of last vaccine dose:
Date of last vaccine dose:
*
/
MM
/
DD
YYYY
Location you are entering/exiting
*
Communication Center
Administration - Anoka
Administration - Riverview
LL2 - Alexandria
LL3 - Willmar
LL4 - Anoka
LL5 - Rice Lake
LL6 - Hibbing
LL7 - Duluth
LL8 - Brainerd
LL9 - Marshfield
LL10 - Rush City
LL11 - Rhinelander
Riverview Education Center
Reason to be at base:
*
Shift / Work
Meeting
Maintenance
Education
Equipment
Other:
Explain other reason:
*
Minimum of
8
characters required.
Currently Entered:
0
characters.
Thermometer available?
*
Thermometer available?
No
Yes
Temperature (via Infrared Thermometer) GREATER THAN 100.4°F or 38°C
*
Temperature (via Infrared Thermometer) GREATER THAN 100.4°F or 38°C
No
Yes, Call MOC or Manager Immediately
Please verify! You have indicated that you have a measured temperature greater than 100.4°F
If this is accurate, please call your Manager or the MOC immediately.
You
must
be wearing a mask/face covering at all times while visiting any Life Link III location.
In the past 14 days have you had any of the following?
● Confirmed Positive COVID-19 Test
● Tested for COVID-19 and are awaiting test results
● Been in contact
without proper PPE
with someone who is pending test results or has tested positive within the last 14 days?
*
In the past 14 days have you had any of the following?
● Confirmed Positive COVID-19 Test
● Tested for COVID-19 and are awaiting test results
● Been in contact
without proper PPE
with someone who is pending test results or has tested positive within the last 14 days?
No
Yes
History Detail:
*
History Detail:
Confirmed Positive COVID-19 Test
Tested for COVID-19 and are awaiting test results
Been in contact
without proper PPE
with someone who is pending test results or has tested positive within the last 14 days
Details
*
Minimum of
5
words required.
Currently Entered:
0
words.
Are you currently experiencing any of the following symptoms?
● Fever (feel feverish?)
● Cough
● Shortness of breath
● Sore throat
● Muscle pain
● Loss of taste or smell
● Abdominal Pain or Diarrhea
● Itchy, red eyes
*
Are you currently experiencing any of the following symptoms?
● Fever (feel feverish?)
● Cough
● Shortness of breath
● Sore throat
● Muscle pain
● Loss of taste or smell
● Abdominal Pain or Diarrhea
● Itchy, red eyes
No
Yes
Symptoms: (select all that apply)
*
Symptoms: (select all that apply)
Fever (feel feverish)
Cough
Shortness of breath
Sore Throat
Muscle pain/body aches
Loss of taste or smell
Abdominal Pain or Diarrhea
Itchy, red eyes