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), 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? *
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 PPE equipment? *
You answered "No" having the required PPE equipment!

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