Free Employee Health & Safety Screening Form Template
Employee Health & Safety Screening Form
Please complete this Health & Safety Screening Form as part of our commitment to ensuring a safe and healthy workplace. Your honest and detailed responses are crucial for proactive health management and safety compliance.
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Personal Information |
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Name: |
[Name] |
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Job Title: |
[Job Title] |
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Department: |
[Department] |
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Date: |
[MM-DD-YYYY] |
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Health Screening Questions |
Yes |
No |
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Have you experienced any flu-like symptoms in the past 14 days (fever, cough, difficulty breathing)? |
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Do you have any known allergies or medical conditions that the employer should be aware of? If yes, please specify. |
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[Peanut allergy and asthma] |
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Recent Travel and Exposure |
Yes |
No |
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Have you traveled internationally within the last 30 days? |
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Have you been in close contact with anyone diagnosed with or suspected of having COVID-19? |
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Workplace Safety Concerns |
Yes |
No |
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Do you have any current workplace safety concerns or suggestions? If yes, please describe. |
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Acknowledgment: I affirm that the information provided is accurate to the best of my knowledge. |
[Signature] |
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Your participation in this screening process helps us maintain a safe working environment for all employees. Thank you for your cooperation.
