TALENT FOR A COMPETITIVE EDGE

COVID-19 Questionnaire

Visitor or Employee?

Visitor

Employee

1.

Have you had any of the following new symptoms in the last seven (7) days: fever or chills, cough (either new, or different than your usual cough), sore throat, shortness of breath, or any other flu-like symptoms?

Yes

2.

Have you traveled internationally or outside of Michigan in the last 14 days?

Yes

3.

In the past 14 days, have you been in close (less than 6 feet), prolonged contact (more than 2-3 minutes) with someone with SUSPECTED or CONFIRMED COVID-19 without using infection protection and control precautions?

Yes

4.

Have you been in close contact with anyone who has traveled internationally or outside of Michigan within the last 14 days?

Yes

If the answer is “yes” to any of the questions or your temperature exceeds 100.4° F, you may not return to work or visit the suite until you satisfy the following…

3 DAYS WITH NO FEVER AND 7 DAYS SINCE THE FIRST SYMPTOM.

14 DAYS IF IN CLOSE CONTACT OF DIAGNOSED CASE OF COVID-19.

14 DAYS FOLLOWING TRAVEL OR IN CONTACT WITH SOMEONE WHO HAS TRAVELED.

Thanks for submitting!

Note: The information above will be used only to determine risk and your ability to work or visit. Your personal answers to this questionnaire are confidential and will be stored in your medical file.