TG Employee Portal 1.1.2.0
Coronavirus (COVID-19) Employee Health Screening Form
Complete and turn this form into your Supervisor every Monday (or your first scheduled day each week) you report to work.


Name:  
Date:05/25/2020
Company:
TGMO
Supervisor:
Abernathy, Scott


In the past 24 hours, have you experienced:
Fever:
Cough:
Shortness of Breath:
Current Temperature:
 

If you have a fever OR answered "yes" to two or more of the symptoms above, please do not
go into work. Report your absence to your Supervisor.

In the past 14 days, have you:
Had close contact with an individual diagnosed with COVID-19:

If you answered "yes" to the question above, please do not go into work. Report
your absence to your Supervisor and self-quarantine at home for 14 days.

Traveled domestically?
If you answered “yes”, please refer to TG’s Domestic Travel Guidelines and provide your Supervisor with dates & location of the travel.
Traveled internationally?
If you answered “yes”, please do not go into work. Report your absence to your Supervisor and self-quarantine at home for 14 days.
Employee Electronic Approval:
 


 

For FATM (First Aid Team Member) ONLY
If an employee's body temperature is at or above 100.4 degrees Fahrenheit, the employee must be sent
home immediately and the following completed by the First Aid Team Member
Date Employee Sent Home:
RadDatePicker
RadDatePicker
Open the calendar popup.
Recorded Temperature:
An employee sent home with a fever can return to work when he or she has been fever free for 24
hours without taking medication.