Health Screening Questionnaire
This form is required to be completed prior to arriving onsite at an ABT facility
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Work Location *
Clock Number *
Do you have a new cough or shortness of breath that cannot be attributed to another health condition? *
Do you have a new sore throat that cannot be attributed to another health condition? *
Do you have a headache or new muscle/body aches that cannot be attributed to another health condition or specific activity such as physical exercise? *
A new onset of congestion or a runny nose that cannot be attributed to another health condition, such as seasonal allergies? *
A new onset of nausea, vomiting or diarrhea that cannot be attributed to another health condition? *
Have you traveled out of State without completing a travel declaration with HR? *
Have you been in a group of more than 50 people? *
Have you been in contact with someone who is being tested for COVID 19, is positive for COVID 19 or has flu like symptoms or a fever of 100.4 or greater? *
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