The safety of our employees is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to entering the worksite. Please do not enter the worksite until your responses have been reviewed and your entry has been approved.
Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and our other employees.
Phone Number (mobile/home)(Required):
NOTE: If you have tested positive for COVID-19 or have been presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms, please contact your manager or human resources representative when: (1) you have had no fever for at least 72 hours (3 full days), without the use of fever-reducing medications; (2) your other symptoms have improved; and at least 7 days have elapsed since your symptoms first appeared.
VACCINE #1 DATE:
VACCINE #2 DATE:
I hereby certify that the responses provided above are true and accurate to the best of my knowledge.
Full Name (Digital Signature Required):