Wellness and Temperature Check - Golden State Restaurant Group

This form must be completed for anyone with an out of range temperature check.
If employee’s temperature is below 99.5 °F, employee may proceed to work their shift.
If employee’s temperature is at or above 99.5 °F the employee may request a second test but must wait fifteen minutes from the time of the first test. Employee should maintain six feet of separation from all employees and guests during this waiting period.
a. If employee’s second test result is below 99.5 °F, employee may work their shift.
b. If employee’s second test result is again at or above 99.5°F, the manager will send employee home and clock the employee out.

Restaurant*

Select form type...*

Temperature Check
Visitor Log

LEGAL Employee Name*

First Last Time Card Number

Wellness and Temperature Check Type*

Start of Shift
Return from Meal Break

Refusal

Employee Refused Temperature Check and is being sent home.

Employee Signature*

Temperature Check

First Temperature Read*

Time of First Screening*

:

Second Temperature Read*

Time of Second Screening*

:

Wellness Check Section

Do you currently have fever, cough, loss of taste, sore throat, shortness of breath or any other COVID-19 OR flu like symptoms (nausea, vomiting, diarrhea, etc.)?*

Yes
No

Have you been diagnosed with COVID-19 by a medical provider?*

Yes
No

In the past 14 days, have you had close contact (within 6 feet for 10 minutes or more, or living in your household) with a person who has been diagnosed with COVID-19 by a medical provider?*

Yes
No

Have you been told by a health care provider or public health official that you should self-quarantine due to potential COVID-19 exposure(s) or that you are suspected of having COVID-19?*

Yes
No

Employee Signature*

Manager Signature*

Visitor Log

What company is the visitor from?*

Date of Visit*

Approximate Visit Start Time*

:

Approximate Visit End Time*

:

Manager Submitting Form:*

Temperature Check Form

Temperature Check

Wellness Check Section

Visitor Log

We are looking for hard working, enthusiastic individuals!