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Staff Screening Questionnaire for Building Entry

  1. Building Entry Screening Form
    In an effort to reduce the risk of COVID-19 exposure to WSWCT staff and visitors, please complete the following screening questions prior to entering the facility.
  2. Do you have a temperature of 100.4 degrees F or above? *
  3. If yes, do not enter the building and contact your supervisor about returning to work.
  4. Have you experienced any of the following symptoms in the last 24 hours? *
    Cough / Shortness of breath or difficulty breathing
    Chills or repeated shaking with chills / Muscle pain
    Headache / Sore throat / Loss of taste or smell / Diarrhea
  5. If yes, do not enter the building and contact your supervisor about returning to work.
  6. Have you or someone in your household, had close contact or cared for someone diagnosed with or suspected of having COVID-19 within the last 14 days? *
  7. If yes, do not enter the building and contact your supervisor about reporting to work.
  8. I attest that all I have answered all questions accurately to the best of my knowledge and upon entry into the building agree to abide by the social distancing, handwashing, cleaning/sanitization, and related protocols established by Workforce Solutions of West Central Texas while in the facility.
  9. Leave This Blank:

  10. This field is not part of the form submission.