COVID-19 SCREENING QUESTIONAIRE

The safety of our members & 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.

Covid Screening

Name
First Last
Date
Date Format: MM slash DD slash YYYY
Please select One*
1. Do you currently have a fever of 100.4 degrees F or greater?*
- No
- Yes
2. Do you have a cough or shortness of breath that began within the past 14 days?*
- No
- Yes
3. In the past 14 days, have you gotten a positive result from a COVID-19 test that tested saliva or used a nose or throat swab? (not a blood test)*
- No
- Yes
4. In the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone who either tested positive for COVID-19 (not a blood test) or developed symptoms of COVID-19 (fever, cough, or shortness of breath)?*
- No
- Yes
5. Have you traveled out of state for more than 24 Hours*
- No
- yes