Covid 19 Safety Survey
Name
First Name
Last Name
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
You are
Staff
Visitor
Other
COVID-19 SAFETY RULES
DO NOT ENTER, if you have been exposed to anyone that has tested positive for COVID-19 within the last 14 days.Â
DO NOT ENTER, if you experienced any COVID-19 symptoms within the past 14 days and CALL & REPORT your symptoms to your manager/supervisor.
DO NOT ENTER, if you have a high temperature. CALL & REPORT your symptoms to your manager/supervisor.
Masks must be worn at all times while indoors.
If you have been vaccinated for Covid-19, PROVIDE a copy of your vaccination card to Human Resources.
Bi-weekly testing is mandatory for all unvaccinated Staff and Participants.
Please answer the following questions.
Rows
Yes
No
Short Notes
Have you been exposed to anyone that has tested positive for COVID-19 within the last 14 days?
1
2
Have you experienced any COVID-19 symptoms within the past 14 days?
3
4
Do you have a high temperature?
5
6
Are you wearing a Mask?
7
8
Have you been vaccinated for Covid-19?
Yes
No
Please provide a copy of your vaccination card.
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of
Have you been tested for COVID-19 within the last 2 weeks?
Yes
No
Please enter date of your last Covid-19 Test.
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Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I, undersigned, agree with the following statements:
I verify that the information I am submitting here is complete and accurate.
I understand and agree with the COVID-19 Safety Rules.
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: