Health Screening Form
Health Screening Form
This form is to be completed before entering
and
after leaving any Life Link III location.
Name
Name
*
First
Last
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
Base you are entering/exiting
*
Communication Center
Riverview Administration
LL2 - Alexandria
LL3 - Willmar
LL4 - Anoka
LL5 - Rice Lake
LL6 - Hibbing
LL7 - Duluth
LL8 - Brainerd
LL9 - Marshfield
Reason to be at base:
*
Shift
Meeting
Maintenance
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 the base
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
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