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COVID-19 Health Screening Form

This COVID-19 Health Screening Form is a document that individuals can fill out upon entering a business' premises to help protect the health and safety of the community. The form, which acts as a declaration of health contains questions regarding common symptoms of COVID-19 and asks if the individual or their immediate family members have come in contact with a confirmed case of COVID-19. If your business is planning on reopening or has already reopened, it is helpful to have this form on hand for guests to fill out.

If you have questions about reopening your business during the COVID-19 pandemic, ask a lawyer or find more resources in our Coronavirus (COVID-19) Legal Center.

Use the COVID-19 Health Screening Form document if:

• You are a business owner who wants to ensure the safety of your staff and customers
• You want to ensure the safety of your employees

If used properly, a COVID-19 Health Screening Form can help to prevent the spread of illness and support contact tracing in a business environment. When making a COVID-19 Health Screening Form, you will need to be sure that your business meets the state and local regulations for reopening and returning to work. Before you allow customers and employees back, it is important that you are following all local rules and regulations. Ask a lawyer if you are unsure about the guidelines that apply to your business.