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Precautionary COVID19 Screening Checklist For Employees

The document is a COVID-19 screening checklist for employees not on duty that collects information about an employee's symptoms, medical history, potential exposure, and manager recommendation on returning to work.

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Mohammad Jahangir Alam
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11 views1 page

Precautionary COVID19 Screening Checklist For Employees

The document is a COVID-19 screening checklist for employees not on duty that collects information about an employee's symptoms, medical history, potential exposure, and manager recommendation on returning to work.

Uploaded by

Mohammad Jahangir Alam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Precautionary 

COVID‐19 Screening Checklist for Employees who are not in Duty  
(Feeling Sick / Sick Leave / Accident Leave / Earned Leave / Compensatory Off / WFD / Duty Rotation / etc.) 
  
Employee Name:    Pay Roll No:        

Super  Department  /  Dept.  /    Reporting   


Section:  Manager: 
Residence Address:    Emirate:   
(Area/Bldg./Room No) 
Type of Residence:    Contact No:   
(Sharing/Family/Bachelor/ESQ) 
Number of Room mates 
Date which Employee performed last duty and left Power Station Premises:     
(dd‐mm‐yyyy) 
 
1. Does the employee have any of the following symptoms? 
 ☐Fever    ☐Cough     ☐ shortness of breath     ☐ Flu      ☐ Other: ___________    ☐  Nil     
 
2. Did the employee visit a clinic/hospital?    ☐Yes    ☐No      If yes,    ☐ for Self    ☐ Accompanying others      
 
3. Did the employee do a COVID19 test?        ☐Yes    ☐No      
 
4. Any history of illness during last 14 days?  ☐Yes    ☐No    If Yes, Pls. specify _______________________ 
 
5. Is the Employee taking any medications?  ☐Yes    ☐No      
 
6. Did the employee get a sick leave?  ☐Yes    ☐No    If yes,    Number of Calendar days:____________  
 
7. If visited a clinic / hospital, what did the doctor advise? ___________________________________________        
 

__________________________________________________________________________________________ 
 

8. Any chance of the employee been in close contact with a COVID19 confirmed case at work / travelling / 
home?                                ☐Yes    ☐No      
 
9. Any chance of the employee been in contact with another sick person with flu symptoms / fever at work / 
travelling / home?           ☐Yes    ☐No      
 
10. Did the employee take any type of leaves during the last 14 days?   ☐Yes    ☐No    
If Yes, Pls. specify type & dates:   ________________________________________________________________ 
 
Manager Recommendation: ___________________________________________________________________ 
 

___________________________________________________________________________________________ 
 
             
Self Declaration: Employee  Verified by: Manager  
   

Signature / Date  Signature / PRN / Date 
 

For HR (Gen) use only: 
Employee Resumed duty on:   

This Form to be filled and forwarded to M‐HR Generation for further approvals.(No Hard Copies allowed) 

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