COVID-19 NOTICE & PRECAUTIONS
THIS FORM MUST BE COMPLETED WITHIN THE TWO (2) HOUR PERIOD PRIOR TO ENTERING THE WORKPLACE. PLEASE READ THE FOLLOWING NOTICE AND PRECAUTIONS CAREFULLY.  BY COMPLETING THIS FORM, YOU ACKNOWLEDGE, AGREE AND REPRESENT THAT YOU HAVE CAREFULLY READ, UNDERSTOOD AND AGREED TO ALL TERMS.
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FIRST NAME *
LAST NAME *
EMAIL (WORK ACCOUNT) *
DATE OF WORKPLACE VISIT *
MM
/
DD
/
YYYY
WORKPLACE YOU ARE ENTERING (i.e., OFFICE LOCATION, VENUE NAME) *
I understand that COVID-19 has been declared a worldwide pandemic by the World Health Organization and that COVID-19 infections and deaths have been confirmed throughout the United States. I understand the known and potential risks of COVID-19, including quarantine, serious illness, disability and death. I also understand, acknowledge and agree that (a) these risks cannot be fully eliminated and are increased by proximity to other people, (b) there is an inherent and elevated risk of exposure to COVID-19 in any public place or place where people are present, and (c) there is no guarantee, express or implied, that I will not be exposed to COVID-19. *
Required
I will notify my supervisor if within the fourteen (14) days prior to entering the workplace I have traveled outside the state or country in which I reside and I understand that, depending on where I have traveled, I may be subject to quarantine requirements. *
Required
I WILL STAY HOME AND NOT ENTER THE WORKPLACE IF I ANSWER "YES" TO ANY OF THE FOLLOWING QUESTIONS:
In the past 14 days, have you been diagnosed with COVID-19? *
In the past 14 days, have you exhibited symptoms of COVID-19, including one or more of the following: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting and/or diarrhea? *
In the past 14 days, have you been in contact with someone who has been confirmed or suspected of having COVID-19? *
While at work, I will follow the recommendations of the Centers for Disease Control and Prevention to reduce the spread of COVID-19, including the following: (1) wearing a cloth face covering while working or in close proximity to other people; (2) avoiding large gatherings and maintaining at least 6 feet of distance from others when possible; (3) washing hands often with soap and water for at least 20 seconds or using hand sanitizer with at least 60% alcohol if soap and water are not available; (4) covering the mouth and nose with a tissue when coughing and sneezing; and (5) practicing routine cleaning and disinfection of frequently touched objects and surfaces and when possible avoiding using other employees’ work tools and equipment (if not possible, clean and disinfect such tools and equipment before and after use). *
Required
If I develop symptoms of COVID-19 while at work, I will immediately separate myself from other people and go home or to a healthcare provider. I will notify my supervisor if I need transport home or to a healthcare provider. *
Required
ALL AEG EMPLOYEES HAVE BEEN ASSIGNED TRAINING REGARDING COVID-19 VIA PALS AND ARE REQUIRED TO COMPLETE SUCH TRAINING PRIOR TO ACCESSING ANY OFFICES/VENUES. IF YOU HAVE NOT COMPLETED THE COVID-19 TRAINING, PLEASE DO SO IMMEDIATELY.
THANK YOU FOR COMPLETING THIS FORM. IF ANY OF YOUR RESPONSES CHANGE AFTER COMPLETING THIS FORM, PLEASE LEAVE THE WORKPLACE AND NOTIFY YOUR SUPERVISOR.
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