Introduction:

This checklist template is part of our Coronavirus Workplace Processes pack.

It was built following the procedures outlined by the US Centers for Disease Control and Prevention (CDC).

If you are an on-site employee, please use this COVID-19 Daily Self Checklist each day before reporting to work.

This checklist is meant to be completed each day by onsite personnel, before reporting to work. It provides a step-by-step guide on checking for COVID-19 symptoms to help limit any further spread of the virus. 

Though this checklist has all the basic necessary information, you can also choose to edit it to better suits your specific needs. You can add/edit form fields and widgets throughout the checklist to help gather necessary information and sync your Process Street account with other software you may be already using to easily store and use the information from your checklists.

When the template is ready and would like to use it, all you have to do is run the template as a checklist.

Process Street is not a medical institution and the items contained in this process template are illustrative and not intended to be understood as medical advice. Please refer to the attached PDF document for any and all medical or operational recommendations.

Record basic details

Use the form fields below to record basic information first.

Check for a fever

Do you have a fever (over 100.30F) without having taken any fever reducing medications?

Check for loss of smell/taste

Check for a cough

Check for muscle aches

Check for a sore throat

Check for a shortness of breath

Check for chills

Check for a headache

Check for nausea/vomiting, diarrhea, loss of appetite

Have you experienced any gastrointestinal symptoms such as nausea/vomiting, diarrhea, loss of appetite?

Assess whether you've been in contact with COVID-19

Have you, or anyone you have been in close contact with been diagnosed with COVID-19, or been placed on quarantine for possible contact with COVID-19?

[Conditional] Stay home

If you replied "Yes" to any of the questions in this checklist, stay home (with pay) and follow the steps below:

  1. Call your supervisor to notify them 
  2. Call/email the COVID-19 HR Response Team at 413-687-2283 or [email protected].

Feel free to use the Send Email form field below to contact the COVID-19 HR Response Team:

[Conditional] Proceed to work

If you answered “No” to all of the questions, you can go to work as normal or visit your work.

If you begin to develop any new symptoms, redo the checklist to reevaluate your fitness to work.

Note: If you're experiencing any other new symptoms that weren't listed in the checklist, then you should stay home and minimize close contact with others until the symptoms pass.

Approval: Final approval

Will be submitted for approval:
  • Record basic details
    Will be submitted
  • Check for a fever
    Will be submitted
  • Check for loss of smell/taste
    Will be submitted
  • Check for a cough
    Will be submitted
  • Check for muscle aches
    Will be submitted
  • Check for a sore throat
    Will be submitted
  • Check for a shortness of breath
    Will be submitted
  • Check for chills
    Will be submitted
  • Check for a headache
    Will be submitted
  • Check for nausea/vomiting, diarrhea, loss of appetite
    Will be submitted
  • Assess whether you've been in contact with COVID-19
    Will be submitted
  • [Conditional] Stay home
    Will be submitted
  • [Conditional] Proceed to work
    Will be submitted

Sources:

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