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 and/or airline industry)
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 (other than airline employees), 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?

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* 11. When you have someone in your household who is currently experiencing symptoms or has been tested for COVID-19 within the past 3 days you must do the following prior to going to work:

1. Regular self monitoring.
2. Wear a mask at ALL times.
3. Social distance at a minimum of 6 ft.
4. Regularly clean & disinfect work spaces.

NOTE: If you become sick during the day you should leave immediately and contact your supervisor by phone.

By checking box below you are acknowledging that you have read and understand this statement.

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