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COVID-19 Mandatory Screening
Purpose: This health survey is intended to provide information/data in order to reduce the spread of COVID-19 among employees.
** COVID-19 information is available on the CDC website **
Write a Testimonial
Name
Date
Time
Do you or anyone in your household currently have or had within the last 24 hours any of the following symptoms:
Fever greater than 100 degrees Fahrenheit
Atypical cough
Atypical Headache
Chills
Repeat shaking/chills
Atypical muscle pain
Atypical sore throat
Vomiting/diarrhea
New loss of taste or smell (unrelated to baseline condition)
Shortness of breath/breathing difficulties (unrelatead to baseline condition)
Have you or someone in your household had close contact (face to face contact within 6 feet) with someone who is ill with cough and/or fever in the last 14 days?
Yes
No
Have you or anyone in your household been in close contact (face to face contact within 6 feet) in the last 14 days with someone who has been tested for COVID-19 or been diagnosed with COVID-19?
Yes
No
Have you or anyone in your household been at a large gathering of people who do not reside in your household and were not able to comply with CDC distancing guildelines in the last 14 days?
Yes
No
Have you been directed by a health department or healthcare provider to self-isolate or self-quarentine in the last 14 days?
Yes
No
Have you traveled out of the Country or on a cruise ship in the last 14 days?
Yes
No
If any of the symptoms have been checked OR you answer YES to any of the questions above, DO NOT enter our office building or job site. Call a partner prior to reporting to work for direction.
Submit Response
Thanks for submitting!
