COVID-19 Screening Form
Please answer the following questions regarding symptoms of COVID-19. Answering "Yes" to any of these questions will result in you being denied entrance to this building.
1. Have you displayed any symptoms of COVID-19 in the last 24 hours? (Symptoms of COVID-19 include fever, tiredness, cough, muscle or body aches, shortness of breath, nausea with vomiting, diarrhea, chills, night sweats, sore throat, headaches, confusion, or loss of sense of taste or smell.) *
2. Has a member of your household displayed any symptoms or tested positive for COVID-19 within the last 2 weeks? *
3. Have you had close contact with an individual who has displayed symptoms of COVID-19 or has tested positive for COVID-19 within the last 2 weeks? (Close contact is considered closer than 6 feet for a prolonged period and/or being coughed or sneezed on.) *
Name *
Phone Number *
Purpose of Visit *
Employer Name (only if working at active construction site)
Date *
MM
/
DD
/
YYYY
I hereby certify that the above statements are true and correct to the best of my knowledge.* *
Required
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy