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Health Screening Form for Employees

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  7. Please answer yes or no to the following questions:
  9. 1.) Have you traveled to or been in close contact with anyone who has traveled outside of New Mexico within the last 14 days?**
  11. 2.) Have you been diagnosed with COVID-19 by a doctor within the last 14 days?**
  13. 3.) Have you been asked to self-quarantine because of COVID-19 and are you still within the quarantine period?**
  15. 4.) Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?*
  17. 5.) Have you experienced any cold or flu-like symptoms in the last 14 days that is not attributable to another condition? [New or worsening cough, shortness of breath or difficulty breathing?]**
  19. 6.) Have you experienced at least two of the following symptoms: Fever, Chills, Muscle Pain, Headache, Sore Throat, New Loss of Taste or Smell?**
  21. By submitting this form, you are acknowledging that you are also agreeing to have your temperature taken as part of the screening process. Employees answering "yes" to any of the above questions or whose temperature exceeds 100.4° F will not be permitted access to the Taos County Building[s].
    If you have any questions about this form, please contact HUMAN RESOURCES.
    22. Leave This Blank:

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