The safety of our employees and their family members is our priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to entering the worksite.
 
Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and our other employees.

Do not enter the worksite if you respond “Yes” to any of the following questions and contact Joann Montanez at (626) 243-1444 for approval to enter.

Note: The information collected on this form will be used to determine whether you may be infected with COVID-19. The information on this form will be maintained as confidential. Any questions should be directed to the Office Manager or your direct supervisor.

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* 1. Are you experiencing any of the following symptoms, or have experienced any of these symptoms in the past 14 days?   

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer), cough, shortness of breath or difficulty breathing, sore throat, new loss of taste or smell, chills, head or muscle aches, nausea, diarrhea, or vomiting.

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* 2. In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?

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* 3. In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?

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* 4. Have you been tested for COVID-19 and are waiting to receive test results?

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* 5. In the past 14 days, have you been on a commercial flight or traveled outside of the United States or in close proximity to anyone who has?

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* 6. Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility?

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* 7. Did you answer "YES" to any of the previous questions?

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* 8. Statement of Acknowledgment

0 of 8 answered
 

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