COVID 19 Your health and wellness is important to us. Temperature Check Form 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*Pick OnePacific Ave #802Wilson Way #969Lower Sacramento Road #3017Lodi Avenue #3580Charter Way #4111Tracy Blvd #4147Ben Holt #4643Elk Grove Blvd #4804Center Street #6216Waterloo Road #7058Louise #8195Floyd #10338Kettleman Lane/99 #10555Galt #10852March Ln. & West Ln. #1179711th Street #12264Martell #13329Wesley #13556Flag City #14444Laguna #17476Patterson #17477Riverbank #17936Holman Road #20612Scenic #22222Union Road #23653Don Avenue #24092Gateway #25489Quail Lakes #25768Laguna Springs #26345Calvine #26895ValPico #32054Spanos Park #32074Daniels Street #32116Lathrop Road #32765Twin Cities #34891Yosemite #35025Bruceville #35050Elk Grove-Florin #35797Sheldon #35911Tracy High #36229Sunwest #36681Select 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* Reset signature Signature locked. Reset to sign again Temperature CheckFirst Temperature Read*Time of First Screening* : Hours Minutes AM PM AM/PM Second Temperature Read*Time of Second Screening* : Hours Minutes AM PM AM/PM Wellness Check SectionDo 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* Reset signature Signature locked. Reset to sign again Manager Signature* Reset signature Signature locked. Reset to sign again Visitor LogWhat company is the visitor from?* Date of Visit* MM slash DD slash YYYY Approximate Visit Start Time* : Hours Minutes AM PM AM/PM Approximate Visit End Time* : Hours Minutes AM PM AM/PM Manager Submitting Form:* We are looking for hard working, enthusiastic individuals! Apply Here
