Free Cleaning Services Health Screening Form Template

Cleaning Services Health Screening Form

This form is designed to assess your current health status and ensure that you are fit for work. Please provide detailed and accurate information and check the option that represents your response. Your cooperation is crucial for maintaining a safe and healthy work environment for all employees.

Personal Information

Field

Information

Name:

Date of Birth:

Gender:

  • Male

  • Female

  • Other:                               

Health Screening Form

Section

Question

Response

Health History

Do you have any pre-existing medical conditions?

  • Yes

  • No

If yes, please specify:

Are you currently taking any medication?

  • Yes

  • No

If yes, please specify:

Symptoms

Do you currently have any COVID-19 symptoms?

  • Yes

  • No

If yes, please specify:

Exposure Risk

Have you been in close contact with anyone diagnosed with COVID-19 in the past 14 days?

  • Yes

  • No

Have you traveled internationally in the past 14 days?

  • Yes

  • No

Temperature Check

Current Temperature:

Time of Measurement:

Health Declaration

I declare that the information provided above is true and accurate to the best of my knowledge. I understand the importance of maintaining a safe and healthy work environment and will adhere to all health and safety protocols.

Date: [Month Day, Year]

Thank you for completing this form. Your health and safety are our top priority. If you have any issues or concerns, please contact [Your Company Email] or call [Your Company Number]. We appreciate your cooperation.

Cleaning Services Templates @ Template.net