DAILY COVID-19 PRE-SCREENING QUESTIONNAIRE

Date

Project Name

TCM SCCO

Subcontractor Company

Employee Name

First NameLast Name

Have you traveled to any CDC listed COVID-19 hotspots both foreign and domestic locations by either ground or air travel?

YesNo

Have you, or anyone in your residence, come in close contact (within 6 feet) with someone who has a suspected or confirmed COVID-19 diagnosis in the past 14 days?

YesNo

Are you currently experiencing OR have experienced int he apst 14 days fever (greater than 100.4 F or 38.0 C) OR symptoms of lower respiratory illness such as cough, shortness of breath, or difficulty breathing?

YesNo

Temperature Screening done?

YesNo

Results of Temperature Screening:

Have you been asked to self-isolate or quarantine by your doctor or public health official?

YesNo

NOTE: If an employee, visitor or vendor answer 'Yes' to any of the above questions, they will be asked to leave the workplace or jobsite immediately and seek medical evaluation. Re-admittance will be allowed only with adequate medical documentation.

Name

First NameLast Name

Signature