Health Screening Questionnaire
All Tridonn Construction Co. employees, subcontractors, vendors, and visitors are required to take this questionnaire prior to physically entering any Tridonn Construction Co. job site. The questionnaire should be taken the same day that you intend to physically be on the job site. If you answer "Yes" to any question, you should contact your supervisor before accessing the job site. You are required to check in with the site supervisor before entering the job site to verify you have filled out the questionnaire.
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Tridonn Construction Co. Project Name *
Company Name *
Name *
Last, First
On what date will you be accessing this job site? *
MM
/
DD
/
YYYY
Have you experienced any of the following "Principal Symptoms" in the last 14 days ? Fever, Sore throat, A new uncontrolled cough that causes difficulty breathing, Diarrhea, Vomiting, Abdominal pain, New onset of a severe headache, New loss of taste or smell. *
Has anyone in your household experienced any of the following " Principle Symptoms" in the last 14 days? Fever, Sore throat, A new uncontrolled cough that causes difficulty breathing, Diarrhea, Vomiting, Abdominal pain, New onset of a severe headache, New loss of taste or smell. *
Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? (Close contact is defined as being within six feet of an individual for 15 minutes.) *
Have you traveled out of the country, out of the state, or to one of Michigan's coronavirus hotspots (City of Detroit, Macomb, Oakland, or Wayne Counties) within the last 14 days? *
If you have answered "Yes" to any of the questions above please give a short explanation for your answer. (Please exclude any names in your explanation)
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