Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

COVID-19 Screening Survey

  1. City of East Lansing's COVID-19 Employee Health Screening Survey

  2. In the past 24 hours, have you experienced:

  3. Shortness of breath or difficulty breathing:*

  4. New or worsening cough:*

  5. Fever (or subjective/felt feverish):*

  6. New loss of taste or smell:*

  7. Fever is a temperature of 100°F or higher.

  8. PLEASE NOTE:

    If you answered “yes” to one (1) or more of the above symptoms, please do not go into work. Immediately contact your supervisor. Self-isolate at home and contact your primary care physician’s office or nearest urgent care facility for direction.

  9. In the past 24 hours, have you experienced two (2) or more of the following:

  10. Chills:*

  11. Headaches:*

  12. Muscle Aches:*

  13. Sore Throat:*

  14. Diarrhea:*

  15. Nausea or vomiting:*

  16. Congestion or runny nose:*

  17. PLEASE NOTE:

    If you answered “yes” to two (2) or more of the above symptoms (in green), please do not go into work. Immediately contact your supervisor. Self-isolate at home and contact your primary care physician’s office or nearest urgent care facility for direction.

  18. In the past 14 days, have you:

  19. Had close contact with an individual diagnosed with COVID-19?*

  20. PLEASE NOTE:

    If you answered "yes" to this question, please contact your supervisor immediately prior to reporting to work.

  21. Leave This Blank: