Nursing Home Staff Health Screening Form

Date:                               

To ensure the safety of our residents and staff, please truthfully complete this form by checking relevant symptoms, disclosing recent contacts or travels, and providing vaccination details, if applicable. Thank you for your cooperation.

Full Name:
Employee ID:
Position:
Department:
Date of Birth:
Contact Number:
Email Address:
Emergency Contact:

Please answer the following questions truthfully and to the best of your knowledge:

Have you experienced any of the following symptoms in the past 14 days? (Check all that apply)

• Fever (temperature > 100.4°F or 38°C)

• Cough

• Shortness of breath or difficulty breathing

• Sore throat

• Loss of taste or smell

• Muscle or body aches

• Fatigue

• Headache

• Congestion or runny nose

• Nausea or vomiting

• Diarrhea

• None of the above

Have you been in close contact with anyone diagnosed with COVID-19 or any other contagious illness in the past 14 days?

• Yes

• No

Have you traveled internationally or to any high-risk areas in the past 14 days?

• Yes

• No

Have you received any COVID-19 vaccinations or booster shots? If yes, please provide dates:

• First dose: [Date]

• Second dose: [Date]

• Booster shot: [Date]

Is there any additional information about your health or recent activities that you would like to disclose?

Acknowledgement

I acknowledge that the information provided in this form is true and accurate to the best of my knowledge. I understand the importance of reporting any changes in my health status to the appropriate personnel at the nursing home.

Signature:

[Your Name]

[Date]

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