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Employee Pre-Shift Survey

Please complete this health screening survey each morning before reporting to work.

Your responses are private and will not be shared with anyone.

Do you have any of these symptoms: fever, aches, cough, shortness of breath, chills, muscle pain, headache, sore throat, new loss of smell?*
- Yes
- No
Have you come in contact with anyone diagnosed with COVID-19?*
- Yes
- No
Are you currently waiting for the results of a COVID-19 test?*
- Yes
- No
Have you traveled outside Maryland over the last 14 days?*
- Yes
- No
Acknowledgements*
- I understand my responsibility to not come to work if I have symptoms of COVID-19 or have recently come into contact with someone who has COVID-19.
- I understand my responsibility to comply with Baltimore Home Cleaning’s health and sanitation standards.
Name*
First Last