NAME OF COMPANY: ELIZABETH'S FOOD CO. SCREENING LOCATION: FRONT LOBBYSCREENING CONDUCTED BY First Name Last Name DATE: TIME: AMPM EMPLOYEE/CONTRACTOR/VISITOR NAME: First Name Last Name
You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT come enter the company’s buildings.
If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps AND notify your manager and HR.
If you answered “Yes” to questions 1 or 2, please DO NOT come into work or plant for visit/appointment
Negative Screen (Cleared). If the individual has no symptoms and no contact to a known or suspected COVID-19 case in the last 14 days they can be cleared to enter the facility.
• Positive Screen (Not Cleared).
SCREENING CONDUCTED BY First Name Last Name PAYROLL TITLE Title DATE: TIME: AMPM