COVID19 Daily Screening Questionnaire 2020

The following daily health screening questionnaire is being used to help prevent the risk of exposure to coronavirus and COVID19 on our job sites, and which is currently required by law. Any employee reporting to work must complete and submit the following information.

Site ID:

Your First Name (required)

Your Last Name (required)

Company (required)

Your Phone Number (required)

Please complete and submit the following questionnaire. All questions require an answer.

1) Health Screening and Symptoms Check

1 - Are you feeling sick today?

YesNo

2 - Do you have a fever (temperature over 100.4 degrees)?

YesNo

3 - Do you have a sore throat, cough or shortness of breath?

YesNo

4 - Other flu-like symptoms?

YesNo

In the past 14 days, have you or anyone in your household:

5 - had close contact with someone who, within the past 10 days, has tested positive for COVID-19?

YesNo

6 - had close contact with someone awaiting test results for COVID-19 due to feeling ill?

YesNo

7 - traveled by air internationally?

YesNo

2) COVID19 Awareness and Preparedness:

Have you been properly trained in COVID19 Awareness by your Employer?

YesNo

Are you equipped with the minimum PPE of gloves, eye protection, face covering and hardhat?

YesNo

Please leave this field empty.

Please complete and submit the following questionnaire. All questions require an answer.

1) Health Screening and Symptoms Check

In the past 14 days, have you or anyone in your household:

If you answered YES to any of the above, you are prohibited from entering the jobsite today. You are eligible to return after the following exclusion periods:

2) COVID19 Awareness and Preparedness:

If you answered NO to either of the Awareness and Preparedness questions, you may not enter the jobsite today. All workers are required to be trained and properly equipped with PPE by their employer. (Next Step / call to action?)