Health Questionnaire
First Name
Last Name
Are you currently experiencing, or have you had within the last 24 hours, any COVID-19 Symptoms – fever (greater than 100.4 degrees), dry cough, chills, sweating, body aches, shortness of breath, sore throat, loss of taste or smell? *
Have you been exposed to anyone who is confirmed sick or experiencing the COVID-19 Symptoms within the last 14 days? *
You answered "Yes" to being exposed to anyone who is confirmed sick or experiencing COVID-19 symptoms.

DO NOT ENTER THE BUILDING! PLEASE CONTACT YOUR SUPERVISOR AND KAREN PETRELL

Do you have appropriate Covid PPE equipment/masks and do you agree to wear such equipment per company policy while in the building? Failure to do so will result in you being asked to leave the building. *
You answered "No" having the required PPE equipment!

Please obtain the appropriate PPE equipment BEFORE OR UPON entering the building.