COVID-19 Questionnaire - United States

COVID-19 Questionnaire

Due to the current COVID-19 Pandemic, we now require all workers and guests to answer this short questionnaire. This document will be considered a legal document and will be provided to the local authorities as required. It is important that the information you provide is accurate.

Date*

Date

Time*

:HourMinutes

Site*

Name*

First NameLast Name

Email

worker@yourcompany.com

Have you completed a self assessment today?*

YesNo

Please complete this Self Assessment. Once complete you may return to finish this assessment.

Have you had any symptoms of COVID-19 in the last 14 days?*

YesNo

Have you completed the required 14 day self isolation?*

YesNo

List of Symptoms

Have you ever tested positive for COVID-19?*

YesNo

Have you completed the required 14 day self isolation?*

YesNo

Has anyone in your household tested positive for COVID-19?*

YesNo

Have you completed the required 14 day self isolation?*

YesNo

Have you travelled outside of your State in the last 14 days?*

YesNo

Have you completed the required 14 day self isolation?*

YesNo

By signing below, I acknowledge the above to be true and will supply the above mentioned certifications.

Signature*