covid-19 report
Today’s Date (mm/dd/yyyy):
Name:
Contact Tel #:
Address:
Current Temperature:
Approximate Time Taken:
Have you taken any medicine to reduce your temperature prior to arriving?:
Yes
No
Are you currently feeling sick?:
Yes
No
What symptoms are you experiencing?:
Are you having any breathing issues?:
Yes
No
Have you traveled outside the current government restrictions?:
Yes
No
Have you been in close contact with anyone that is being tested due to symptoms of Covid 19 or treated for Covid 19?:
Yes
No
Have you tested positive or been in close contact with anyone that has been tested positive for Covid 19? If yes, when did you test positive or when were you last in contact with a person who tested positive? If 14 days or more with no symptoms this is a "NO" answer and the person can proceed to work. If 14-days or less this is a "YES" answer and they cannot continue to work. Please refer them to a Safety Representative or Supervisor.:
Yes
No
Notes:
Name of Temperature Taker:
Nigina Zokirova
Dmytro Zhurba
Farkhat Valiyev
Alexander Shaporov
Loreana Rodriguez
Richard Marini
Signature:
Send report
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