EMPLOYEE COVID-19 SCREENING QUESTIONNAIRE

The safety of our employees, clients & guests is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following guidelines 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 other employees & guests.

Note: The information colected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential. Any questions should be directed to Amy Shaw and Melanie Trusty, 517-265-9644.