Covid19 | Pro-MEC Engineering

COVID-19 Workplace Health Screening

First Name

E-Mail Address

Last Name

Current Temperature

In the last 14 days, have you developed any of the following symptoms that are new/different/worse from baseline of any chronic illness:

Fever of 100.4 F or higher, or felt feverish

New or worsening cough

Shortness of breath or difficulty breathing

I understand that if I selected ONE (1) of the above symptoms, I am NOT supposed to go to work and MUST contact Brad Kramer for direction.

Yes

In the last 14 days, have you developed any of the following symptoms that are new/different/worse from baseline of any chronic illness:

Chills

Headache

Sore throat

Loss of taste or smell

Runny nose or congestion

Muscle aches

Abdominal pain

Fatigue

Nausea

Vomiting

Diarrhea

I understand that if I selected TWO (2) or more of the above symptoms, I am NOT supposed to go to work and MUST contact Brad Kramer for direction.

Yes

I confirm that in the past 14 days, I have not had close contact with an individual diagnosed with COVID-19.

Yes

I understand that if in the past 14 days, I have had close contact with an individual that has been diagnosed with COVID-19, I will NOT go into work and immediately contact Brad Kramer.

Yes