Kaltz Excavating Co. Inc/MUE Inc. COVID-19 Employee Health Screening

If the answer is Yes to any of the questions, follow the requirements of the Company’s COVID-19 Employee Exposure Procedure.
**If your body temperature is equal to
or greater than 100 degrees Fahrenheit follow the requirement of the Company's COVID-19
Employee Exposure Procedure.

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* 1. Today's Date:

Date
Time

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* 2. What is your last name?

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* 3. What is your first name?

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* 4. What company do you work for?

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* 5. Please select your the name of your supervisor from the options below:

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* 6. Have you returned from any travel,
international or domestic, within the
past 14 days?

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* 7. Have you been in direct contact or close
contact (within 6 feet) with people (other than medical professionals)
exposed to or diagnosed with COVID-19
within the past 14 days (e.g., being
coughed on, sneezed on, or contacting
shared surfaces)?

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* 8. Have you been in direct contact or close
contact (within 6 feet) with anyone who
has traveled, internationally or
domestically, within the past 14 days?
(e.g., being coughed on, sneezed on, or
contacting shared surfaces).

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* 9. Have you experienced any cold or flulike
symptoms in the last 14 days?
This includes fever; abdominal
discomfort (nausea or diarrhea); cough,
sore throat or runny nose (not
attributable to normal sinus or allergies);
respiratory illness; or difficulty
breathing/shortness of breath

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* 10. Is your body temperature greater than or equal to 100 °F?

0 of 10 answered
 

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