Template

COVID-19 Employee Pre-Site Self Assessment

by Philip Davison, from the Community

60+

This COVID-19 employee pre-site self assessment helps screen staff before attending a worksite. It asks about close contact with COVID-19 cases, medical direction to self-quarantine, recent symptoms such as fever, cough, shortness of breath, sore throat, muscle aches, or loss of taste or smell, and overall wellness. Clear guidance advises employees who answer Yes to stay home, notify their line manager per the handbook, and book a test if symptoms are COVID-19 related. The form captures date and signature for recordkeeping.

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About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
COVID-19 Employee Screening Questionnaire
Use this COVID-19 employee screening questionnaire to assess staff before work. Capture project details, employee name, date, location, temperature results, and PPE status. Ask about recent exposure, self-quarantine orders, and key symptoms such as fever, cough, shortness of breath, sore throat, muscle aches, or loss of taste or smell. Includes guidance on next steps if any answer is yes and space for Health and Safety Officer and employee signatures. Intended as a starting template; seek professional advice for your workplace.
by SafetyCulture
Downloads: 200+
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Template
COVID-19 Symptoms Checklist
Use this COVID-19 symptoms checklist to screen students, staff, and families before entering school or work. The form lists common symptoms such as fever, cough, shortness of breath, chills, fatigue, muscle aches, headache, loss of taste or smell, sore throat, congestion, nausea, vomiting, and diarrhea, and includes exposure and quarantine questions. Follow the guidance to stay home, contact the school, or seek medical care when necessary.
by Lucid Film, from the Community
Downloads: 30+
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Template
COVID-19 Jobsite Visitor Questionnaire
This COVID-19 jobsite visitor questionnaire helps screen visitors before entering a worksite. It captures project and visitor details, date, reason for visit, health and safety officer, and location. The form asks about confirmed COVID-19 diagnosis, recent symptoms such as fever, cough, shortness of breath, sore throat, muscle aches, and loss of taste or smell, and recent exposure to confirmed or symptomatic cases, including recent travel exposure. It concludes with sign-offs from the health and safety officer and the visitor to document acknowledgement. Use this template to standardize screening and support safer site access control.
by SafetyCulture
Downloads: 80+
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Template
COVID-19 Return to Work Sign-In Form
This return to work sign-in form helps organizations screen staff before re-entry to the workplace. It records employee and manager details, asks about COVID-19 symptoms, recent diagnosis, close contact and medical advice to self-isolate, and captures additional notes. Employees provide a signature to confirm declarations. Use as a guidance template and adapt to your policies and local regulations.
by SafetyCulture
Downloads: 20+
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COVID-19 Employee Pre-Site Self Assessment

With SafetyCulture you can

Digitize team workflows

Reduce manual errors

Create and share inspection reports

About author

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COVID-19 Employee Screening Questionnaire

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COVID-19 Employee Screening Questionnaire

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