COVID-19 Screening – Hillview Court

COVID-19 Screening - Hillview - English

First Name:*
Last Name:*
Date:*
Time:*
Temperature:*
Are you experiencing any COVID-19 symptoms?*
Are you experiencing any COVID-19 symptoms?
- Yes
- No
Have you been exposed to anyone that has been diagnosed with COVID-19?*
Have you been exposed to anyone that has been diagnosed with COVID-19?
- Yes
- No
I confirm that I or immediate family (those in home), or anyone I have been in close contact with over a long period of time have not had international travel within the last 14 days, do not have a fever, cough, or sore throat, have not had contact with someone under investigation for Coronavirus (COVID-19) in the last 14 days*
I confirm that I or immediate family (those in home), or anyone I have been in close contact with over a long period of time have not had international travel within the last 14 days, do not have a fever, cough, or sore throat, have not had contact with someone under investigation for Coronavirus (COVID-19) in the last 14 days
- Yes
- No
I confirm that I will use the below hygiene etiquette when away from work or project, and I will not return to project if I suspect I have any symptoms or have been exposed to anyone with symptoms. Hygiene Etiquette per OSHA recommendations: ▪ Frequently wash your hands with soap and water for at least 20 seconds. When soap and running water are unavailable, use an alcohol-based hand rub with at least 60% alcohol. Always wash hands that are visibly soiled. ▪ Avoid touching your eyes, nose, or mouth with unwashed hands. ▪ Avoid close contact with people who are sick. ▪ Clothing shall be sanitized and washed prior to wearing again.*
I confirm that I will use the below hygiene etiquette when away from work or project, and I will not return to project if I suspect I have any symptoms or have been exposed to anyone with symptoms. Hygiene Etiquette per OSHA recommendations: ▪ Frequently wash your hands with soap and water for at least 20 seconds. When soap and running water are unavailable, use an alcohol-based hand rub with at least 60% alcohol. Always wash hands that are visibly soiled. ▪ Avoid touching your eyes, nose, or mouth with unwashed hands. ▪ Avoid close contact with people who are sick. ▪ Clothing shall be sanitized and washed prior to wearing again.
- Yes
- No
Consent*
- I agree the above information is true and accurate.
Email
This field is for validation purposes and should be left unchanged.