Employee Health & Safety Screening Form
Please complete this Health & Safety Screening Form as part of our commitment to ensuring a safe and healthy workplace. Your honest and detailed responses are crucial for proactive health management and safety compliance.
Personal Information |
Name: | [Name] |
Job Title: | [Job Title] |
Department: | [Department] |
Date: | [MM-DD-YYYY] |
Health Screening Questions | Yes | No |
Have you experienced any flu-like symptoms in the past 14 days (fever, cough, difficulty breathing)? | | |
Do you have any known allergies or medical conditions that the employer should be aware of? If yes, please specify. | | |
[Peanut allergy and asthma]
|
Recent Travel and Exposure | Yes | No |
Have you traveled internationally within the last 30 days? | | |
Have you been in close contact with anyone diagnosed with or suspected of having COVID-19? | | |
Workplace Safety Concerns | Yes | No |
Do you have any current workplace safety concerns or suggestions? If yes, please describe. | | |
|
Acknowledgment: I affirm that the information provided is accurate to the best of my knowledge. | [Signature] |
Your participation in this screening process helps us maintain a safe working environment for all employees. Thank you for your cooperation.
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