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COVID-19 Screening
Jobsite Screening for Employees
First Name
Last Name
Select a date
Jobsite Name
Have you been in close contact with anyone diagnosed with COVID-19 in the last 14 days?
*
Yes
No
Have you experienced any symptoms of fever, cough, shortness of breath, sore throat, or diarrhea?
*
Yes
No
I certify that the above information is accurate to the best of my knowledge and understand this is a legal representation of my signature
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Submit
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