Health Questionnaire

First Name *

First Name

Last 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? *

Yes

Have you been exposed to anyone who is confirmed sick or experiencing the COVID-19 Symptoms within the last 14 days? *

Yes

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. *

Yes

You are clear to enter the building. Please remain safe.

You answered "No" having the required PPE equipment!

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