DAILY TEMPERATURE AND SYMPTOM MONITORING SHEET
Self-monitor for signs and symptoms.
Contact Provita Quality (
[email protected]) with line manager and HR for further advice. For contractors and non-
staff, kindly send to your point of contact in our facility.
Take your temperature twice a day, preferably morning and afternoon. Monitor for fever and any respiratory symptoms by
putting check mark if Yes and X if no. Should you have any, please seek immediate advice from physician.
Day: Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Date: 21/03/2021 22/03/2021 23/03/2021 24/03/2021 25/03/2021 26/03/2021 27/03/2021
AM PM AM PM AM PM AM PM AM PM AM PM AM PM
Time of check 9AM 4PM 8AM 7PM 8PM 9PM 8AM 9PM 7AM 7PM 8AM 9PM 7AM 9PM
Directly
Observed
(Y/N)
Temperature 36.3 36.7’C 36.2°C 36.2’C 36.2 °C 36.5°C 36.2°C 36.3 36.7’C 36.3 36.3 36.7’C 36.3 36.7’C
Fever -- -- -- -- -- -- -- -- -- -- -- -- -- --
Cough -- -- -- -- -- -- -- -- -- -- -- -- -- --
Shortness of
breath /
Difficulty of
breathing no no no no no no no no no no no no no no
Chest pain -- -- -- -- -- -- -- -- -- -- -- -- -- --
Other
(specify)
No symptoms
Day: Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14
Date: 28/03/2021 29/03/2021 ___/___/2021 ___/___/2021 ___/___/2021 ___/___/2021 ___/___/2021
AM PM AM PM AM PM AM PM AM PM AM PM AM PM
Time of check 6AM 9PM 7AM
Directly
Observed (Y/N)
Temperature 36.7’C 36.7’C 36.3 ___°C ___°C ___°C ___°C ___°C ___°C ___°C ___°C ___°C ___°C ___°C
Fever -- -- --
Cough -- -- --
Shortness of
breath /
Difficulty of
breathing no no no
Chest pain
Other
(specify)
No symptoms
The above information is true and correct to the best of my knowledge and belief.
Staff Name and Signature: _BEVERLY E. TRINIDAD_ Date: __29-03-2021___
Line Manager Name and Signature: _______________________ Date: ___________________________
Infection Control Name and Signature: ______________________Date: __________________________
