COVID-19 Health Assessment Form COVID-19 Health Assessment FormWorkplace safety is our highest priority. To prevent the spread of COVID-19 and reduce the potential risk of exposure to our team members and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in our facility. This form must be completed before you enter the job site each day, until further notice. Any affirmative responses to the below questions must be reviewed immediately with your Supervisor. Do NOT enter the workplace if you have responded yes to any question until you are evaluated and receive further direction following CDC protocol. Please enable JavaScript in your browser to complete this form.Name *Organization *ContractorClientEmployeeCompany Name *Phone Number *Project Name *Work Site Zip Code *Are you experiencing any of the following symptoms not explained by a known medical or physical condition? *Fever over 100.4 FUncontrolled coughShortness of breathLoss of taste or smellMuscle achesSore throatSevere headacheSevere diarrheaVomitingAbdominal painNone of the aboveHave you had close contact within the last 14 days with someone diagnosed with COVID-19 or who has experienced COVID-19 related symptoms? *YesNo Close Contact is proximity, within 6 feet, to an individual for a prolonged period of time, over 10 minutes.Have you traveled out of country within the last 14 days? *YesNoSubmit
