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SBSCFC Staff Symptom Monitoring
Please fill this form out prior to starting your shift at SBSCFC
Indicates required field
Dept & Location of Work
Work Shift Hrs.
PART 1: Do you have any seasonal allergies? If yes, take your allergy medications each day.
PART 2: Symptoms
Do you have the following symptoms? Click if YES
Fever / Chills
Sudden lack of taste or smell without nasal congestion
New onset headache
New onset pain (muscular, chest, abdomen, joints)
New Intense fatigue
New sever loss in appetite
One (1) or more of the above symptoms = stay home and call your supervisor for further direction.
PART 3: Decision and plan
No symptoms or doesn't meet criteria for off work:
Go to work. Please submit this form by click the SUBMIT button at the bottom left. Please remember to perform hand hygiene before, throughout and after your shift, and wear a procedure mask if you are within 2 meters of a child or coworker.
Symptoms that warrant staying home:
* Call : Call your manger/supervisor as early as possible to determine course of action. If you have further questions, please print or take note of your form results, and contact KMHC Testing Hotline at 450-638-3930 ext. 2296 or 2275 to determine if testing is needed.
If you are experiencing true distress and are very unwell, please call the ambulance.
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