COVID-19 SELF-ASSESSMENT All responses are confidential and submitted directly to Kate Hildebrandt e: kroth@leojroth.com c: 585.261.1876 OK Question Title * 1. Good Morning! How are you feeling today? Healthy Somewhat Healthy Not Healthy OK Question Title * 2. Do you, or anyone you're working with, have any of the following symptoms? Fever Sore Throat Difficulty Breathing Muscle Pain New Loss of Taste or Smell None Other (please specify) OK Question Title * 3. Do you have a fever? Yes No OK Question Title * 4. Have you, or anyone you're working with, traveled or done anything outside of your normal routine? No Yes - Please specify OK Question Title * 5. Have you, or anyone you're working with, been exposed to someone being treated for COVID-19 or who has symptoms compatible with COVID-19? No Yes - Please specify OK Question Title * 6. Do you need any additional PPE (Mask, Gloves, Sanitizer, Etc.)? No Yes - What do you need? OK Question Title * 7. Name (Foreman - Please list everyone onsite with you as well) OK Question Title * 8. Has anyone on your site called in sick today? OK Question Title * 9. Job Site OK Question Title * 10. Anything else we can help out with? OK SUBMIT RESPONSE >>
