Covid19 Questionnaire - Town of Orchard Park

EMPLOYEE & VISITOR COVID-19 SCREENING QUESTIONNAIRE

The safety of our employees and visitors is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire to their manager/supervisor prior to beginning work and immediately after swiping/signing in daily. Visitors should hand it in to the assigned person within each department.

Please respond to each of the following questions truthfully and to the best of your ability.

Your participation is important to help us take precautionary measures to protect you and all employees.

Name *

Phone *

1. Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms?

Fever (100° F/ or greater as measured by an oral thermometer) *

YES

Cough *

YES

Shortness of breath or difficulty breathing *

YES

Sore throat *

YES

New loss of taste or smell *

YES

Chills *

YES

Head or muscle aches *

YES

Nausea, diarrhea, vomiting *

YES

2. In the past 14 days, have you been in close proximity (within 6’) to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact? *

YES

3. In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19? *

YES

4. In the past 14 days, have you been on a commercial flight or traveled outside of the United States, or are you returning from a state requiring a 14-day quarantine based on the Governor’s directive? *

YES

CERTIFICATION: I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Reset Signature

Date

NOTE: Information provided on this form will only be used to determine if you may be infected with COVID-19. This information will be maintained as confidential. Questions should be directed to a manager or our human resources representative.