COVID 19 Kitt Construction Questionnaire

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* 1. What is your name?

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* 2. What is the name of company you are representing?

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* 3. What is the job name?

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* 4. Is your temperature BELOW 100.4 degrees Farenheit today?

Yes

No- If no- leave job site immediately before entering and contact your supervisor.

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* 5. Do you have any COVID 19 positive members in your household?

Yes- If yes- do not enter job site and contact your supervisor immediately.

No

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* 6. Do you have a cough?

Yes- If yes, do not enter job site and contact your supervisor immediately.

No

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* 7. Do you have shortness of breath?

Yes- If yes, do not enter job site and contact your supervisor immediately.

No

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* 8. Do you have fatigue or muscle aches?

Yes- If yes, do not enter job site and contact your supervisor immediately.

No

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* 9. Do you have a new loss of taste or smell?

Yes- If yes, do not enter job site and contact your supervisor immediately.

No

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* 10. Do you agree to report the onset of ANY of these symptoms during your shift?

Yes

No