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PCFR Employee Screening Form

  1. This form should be completed for each apparatus with ongoing crew members each morning by 1000 each day.

    **The BC or EMS Supervisor should be immediately notified of any employee that does not pass screening – do not rely on automated email for notification.**
  2. As the officer overseeing the crew listed above, I have completed the screening question below and verify that the crew does not present with signs or illness or flags for potential COVID-19 exposure.
  3. Does the employee present with a fever?
  4. Does the employee have symptoms of a respiratory infection?
  5. Has the employee traveled internationally within the past 14 days?
  6. Has the employee had close contact with a known or suspected COVID-19 case in the past 14 days?
  7. Has the employee traveled within the U.S. by airplane within the past 14 days?
  8. Leave This Blank:

  9. This field is not part of the form submission.