COVID-19 Screening Form
Pre-visit screening for symptoms, exposure, and vaccination status.
Free · No credit card required · 11 fields · Customize everything
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What's Included
11
Fields
1
Steps
2
Categories
1
Industries
Form Fields
This template includes 11 fields. Here's what respondents will see:
| Field | Type | Required |
|---|---|---|
| Full Name | short answer | Yes |
| Date of Birth | date | Yes |
| Phone Number | phone | Yes |
| Are you currently experiencing any COVID-19 symptoms? | radio | Yes |
| Symptoms (check all that apply) | checkbox | No |
| Have you tested positive for COVID-19 in the last 14 days? | radio | Yes |
| Have you been in close contact with a confirmed COVID-19 case in the last 14 days? | radio | Yes |
| Temperature (°F) | numerical | No |
| Have you traveled internationally in the last 14 days? | radio | Yes |
| Vaccination Status | dropdown | Yes |
| Date of Most Recent Vaccine | date | No |
Frequently Asked Questions
Can this form be used for daily workplace screening?
Yes. The form is short enough to complete in under a minute. For daily use, remove the vaccination fields or move them to a one-time intake form.
Does this template comply with current CDC guidance?
The symptom list mirrors CDC's published COVID-19 symptoms. Public-health guidance evolves — review the form periodically and update fields as needed.
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