MWI COVID-19 Screening Checklist
By completing this form, I acknowledge that Mel Wheeler, Inc. is requesting this information in order to provide a healthy workplace for my co-workers and me. I understand this document and the information provided will be treated as a confidential medical record by the Company, and only disclosed or used as permitted by law.

I understand the Company is relying on my honesty, and I can be disciplined for making a false statement.
Name: *
Today's Date *
MM
/
DD
/
YYYY
In the past 24-hours, have you experienced: *
Required
If you answered ‘yes’ to any of the symptoms above, please do not come to the station. Please self-isolate at home, and contact your doctor for direction.
ADDITIONAL QUESTIONS
Have you had close contact in the last 14-days with an individual diagnosed with COVID-19, who is awaiting a COVID-19 test result, or who has exhibited symptoms of COVID-19? *
Have you engaged in any activity or travel within the last 14-days which fails to comply with the Phase one or Phase two Virginia state guidelines? *
Have you been directed or told by the local health department or your healthcare provider to self-isolate or self-quarantine? *
If you answered "yes" to any of the additional questions above, please do not go into work. Self-quarantine at home for 14-days.
If you test positive for COVID-19 or are experiencing symptoms of COVID-19, you should follow all orders as directed by your healthcare provider. You must have a written notice from your healthcare provider before returning to work. If you have any questions about this questionnaire, please contact Cheryl.
Submit
Never submit passwords through Google Forms.
This form was created inside of tonybroom.com. Report Abuse