Employee Screening Questions //// In response to the recent Coronavirus Outbreak, we are asking that all employees complete the following questionnaire. If you have any questions or concerns related to this form, please contact Sarah Logar at firstname.lastname@example.org. Your Name (required) Your Email (required) Have you been diagnosed with a case of coronavirus (COVID-19) in the last 14 days? (required) YesNo Have you been directed to self-quarantine by any hospital or health agency in the last 14 days? (required) YesNo Have you traveled internationally in the last 14 days? (required) YesNo Have you traveled to any of the following locations in the last 14 days? (required) New Rochelle, NYKing County, WASnohomish County, WANone Have you traveled on a cruise ship in the last 14 days? (required) YesNo Have you been in close contact with anyone that has traveled to any of these locations within the past 14 days? “Close contact” is any person being within approximately 6 feet of a COVID-19 case; lives in the same household as, being an intimate partner of, or providing care for a person with a COVID-19 case; or having direct contact with infectious secretions of a COVID-19 case (being coughed on). (required) YesNo In the last 14 days, have you been in contact with a confirmed novel coronavirus (COVID-19) patient within the past 14 days? (required) YesNo In the last 14 days, have you been in contact with a person who is currently being screened for COVID-19 or under corona virus quarantine?(required) YesNo Are you currently experiencing the following symptoms? (required) FeverCoughShortness of BreathNone Please leave this field empty.