TG Employee Portal 1.4.0.0
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:10/23/2020
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 "primary exposure" to an individual diagnosed with COVID-19? (Primary Exposure: 6ft or closer for 10-15 minutes or longer to someone diagnosed with COVID-19):

If you answered "yes", please contact your supervisor and TG HR and refer to TG's
COVID Flowchart for next steps.

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.