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COVID-19

In an effort to reduce the risk of COVID-19 exposure to employees and contractors, all individuals must complete the following screening questions. Please read each question carefully and select the answer that applies. No health information or questionnaire answers will be shared. We appreciate your cooperation with this matter.

Project Screening

First Name

Last Name

Company

Phone

Project Name

Do you have any symptoms consistent with COVID-19 such as fever, cough, shortness of breath, or any other symptoms?

Have you been in close contact with anyone who has any symptoms consistent with COVID-19 such as fever, cough, shortness of breath, or any other symptoms?

Have you been in close contact with a COVID-19 patient, or are you aware of close contact with someone who has been in contact with a COVID-19 patient?

Have you traveled in the past 14 days, or have a household member who has traveled to an area with an outbreak or sustained transmission of COVID-19? Examples: cruise ships, travel outside of the U.S., even if you are asymptomatic. CDC Guidelines apply.