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2. Before you enter the workplace each day, daily wellness self-screenings are a requirement for entry into the workplace under Washington’s Healthy Washington: Roadmap to Recovery. If you are unable to complete the online form you will need to complete the manual form and provide to your supervisor as you report to work. In completing either form you need to take your temperature and respond accordingly. Anyone that has not completed the required screening process will not be allowed access to the workplace. *
4. Please select the date and time of screening.*
   Please select the date and time of screening.

   Please select the date and time of screening.
6. 1. In the last 48 hours have you had any of the following symptoms that are not attributable to another condition? Check all that apply or “C” that none of them apply. *

   1. A. Cough
   2. B. Shortness of breath
   3. C. I have not experienced any of the symptoms listed above
8. 2. In the last 48 hours have you had any of the following symptoms that are not attributable to another condition? Check all that apply or “J” if none of them apply. *

   1. A. Fever
   2. B. Chills
   3. C. Muscle or body aches
   4. D. Sore throat
   5. E. Headache
   6. F. New loss of taste or smell
   7. G. Congestion or runny nose
   8. H. Nausea or vomiting
   9. I. Diarrhea
   10. J. I have not experienced any of the symptoms listed
10. 3. Within the last 14 days, has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection?*

    1. Yes
    2. No
12. 4. Within the past 14 days, have you been in close contact with anyone that you know that had COVID-19 or COVID-like symptoms? Contact is being 6 feet or closer for more than 15 minutes with a person or having direct contact with fluids from a person with COVID-19 (for example, being coughed or sneezed on).*

    1. Yes
    2. No
14. 5. Have you had a positive COVID-19 test for active virus in the past 10 days?*

    1. Yes
    2. No
16. 6. Have you taken your temperature today?*

    1. Yes
    2. No
18. If yes, was it below 100.4 degrees?*

    1. Yes
    2. No
20. Please select your department*
    -- Select One --AdministrationCommunity DevelopmentFinanceHuman ResourcesPolicePublic WorksCity CouncilContractor

    (Including outside contractors)
22. Electronic Signature*
    By submitting this form you certify that you have answered this form truthfully to the best of your ability.
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23. Submit

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