COVID-19 Pre-Screening Form

Contractor’s Name*

First Last

Email Address*

Phone Number*

Today's Date*

Although exposure is unlikely, do you accept the risk and consent to work on this job site?*

Yes
No

Have you and/or anyone in your household had close contact with a someone who has or is suspected to have Covid-19?*

Yes
No

In the past 14 days, have you and/ or any member of your household been in close contact with anyone experiencing any of the following: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*

Yes
No

Have you or a member of your household traveled outside the United States in the last 14 days?*

Yes
No

Did you quarantine 14 days after return, or did you receive a negative COVID test result at least 3 days after your return?*

Yes
No

Have you or a member of your household traveled by plane in the last 14 days?*

Yes
No

Did you quarantine for 10 days after your travel, or did you receive a negative COVID test after your return?*

Yes
No

In the past 14 days, have you or a member of your household experienced any of the following: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*

Yes
No

Have you or a member of your household tested positive to COVID-19?*

Yes
No

Has it been at least 10 days since you were symptomatic, or did you receive a subsequent negative COVID test?*

Yes
No

If on-site, enter your temperature reading taken by the authorized representative.

If on-site, upload a picture of your thermometer temperature reading taken by the authorized representative.

Max. file size: 50 MB.

Enter your initials below to acknowledge the following statements: You understand that you may not be permitted to the jobsite if you have come in close contact with someone who has COVID-19, have recently received a positive test for COVID-19, or have symptoms of COVID-19, which include: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea?* You understand that we will screen everyone prior to entry for fever. No person with a temperature of 100ªF or higher will be permitted to enter. You understand everyone is asked to abide by social distancing guidelines (6ft or greater) when possible. You understand that a face mask is required to be worn by everyone covering the nose and mouth. Face masks may be removed when eating or drinking within the designated food and beverage areas. You understand that sanitization practices must be followed including sanitizing all equipment prior to usage, hand-off, and packing. Good hand washing practices will be required. Additional hand sanitization is requested prior to consuming food and beverage. You understand that you are obligated to report if you develop any symptoms of COVID-19 or receive a positive test up to 14 days after your final day of work on this program. Please contact the COVID-19 Compliance Officer with any additional questions, or if you develop any symptoms up to 14 days after.*

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COVID-19 Pre-Screening Form

To ensure the health and safety of our staff, clients, and vendors, please complete this confidential document. You will also be asked for any updates by our compliance team each day you are on-site.

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