Field Sales Team Daily Health Check
Name
*
First Name
Last Name
Your Partner Email Address (@partner.samsung.com)
*
example@example.com
Manager's Email Address
*
b.philips@partner.samsung.com
daria.s@partner.samsung.com
john2.s@partner.samsung.com
r.boyal@partner.samsung.com
t.ganson@partner.samsung.com
j.laranjeiro@partner.samsung.com
Today's Date
*
-
Month
-
Day
Year
Date
1. Are you sick with a cold/flu or are you displaying any signs of COVID-19 and/or flu-like symptoms?
*
Yes
No
2. Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?
*
Yes
No
3. Have you travelled outside of Canada or your province of residence in the past 14 days?
*
Yes
No
4. In the past 14 days did you have close contact with someone who has a probable or confirmed case of COVID19?
*
Yes
No
5. In the past 14 days did you have close contact with a person who had acute respiratory illness that started within 14 days of their close contact to someone with a probable or confirmed case of COVID-19?
*
Yes
No
6. In the past 14 days did you have close contact with a person who had acute respiratory illness who returned from travel outside of the country in the 14 days before they became sick?
*
Yes
No
7. In the past 14 days have you been directed by Public Health to self-isolate?
*
Yes
No
By entering your initials below, you acknowledge that all of the above answers are correct and if you have answered yes to any of the above please contact your manager and do not visit any stores.
*
Submit
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