COVID 19 SCREENING

The following form is to be used each morning by employees at ViaTRON if they have or been exposed to any symptoms of COVID-19. Answering YES to any question requires employee to not come to work without a Negative COVID-19 test.

Name

First Name

Last Name

Phone

Do any of these apply to you today?

Checking any of these boxes below will require a Negative COVID-19 test prior to working.

Have you experienced symptoms of COVID‐19 in the past 48 hours?

Have you tested positive for COVID-19 in the past 10 days?

Are you isolating or quarantining because you may have been exposed or are you worried you may be sick with COVID‐19?

Have you been diagnosed with COVID-19 by a licensed healthcare provider (for example, a doctor, nurse, pharmacist, or other) in the past 10 days?

Have you been told that you are suspected to have COVID-19 by a licensed healthcare provider in the past 10 days?

Does anyone in your household currently Positive for COVID-19?

Date

YYYY