Form Center

Pasco County Forms
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.

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.