UFCRS Daily Health Screening Survey
Welcome to the Union Fire Company & Rescue Squad. Thank you for volunteering to serve our neighbors. In order to provide a safe environment for all involved, please complete this short questionnaire just prior to your shift. The following information is required by Governor Murphy's Executive Order #192.

Visit, https://drive.google.com/file/d/1Z3CSS45smZM1UWWcmXB6aSi9I3XuLJ9n/view?usp=sharing, to view the document.
Sign in to Google to save your progress. Learn more
Email *
What is your first & last name? *
At what phone number may we contact you? *
When you took your temperature, was it over 100.4 degrees? *
Are you experiencing any of the following within the past 48 hours? (that is not a symptom that you normally experience) *
Required
If "Other" was selected above, please explain:
Have you recently lost your sense of taste or smell? *
Within the past 14 days, have you had close contact with someone who has tested positive for COVID-19, without wearing PPE? (CDC Defines close contact as being within 6 feet of someone for greater than 15 minutes in a 24 hour period OR living in the same house as a COVID-19 positive person). *
Have you attended a gathering of more than 10 people (indoors) or 25 people (outdoors) within the past 5 days? *
Thank you. If you have answered YES to any of the above, or checked more than 2 symptoms, please do NOT enter the building or respond to a call. Please contact Doug Pszczolkowski (609) 751-1535 for help or clarification.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Union Fire Company & Rescue Squad. Report Abuse