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EMPLOYEE SELF-ASSESSMENT


This was a project I worked on so we could make sure we could do contract tracing across all of our facilities. The main functionality is through jQuery. All information was sent to and stored in a secure database. The employee name and phone number would auto populate from the SharePoint system. Any employee who answered with a flagged item would be contacted immediately by a member of HR before being allowed on site, to make sure we didnt expose other workers.

Our Company is concerned for the safety of our employees. In the interest of ensuring a safe and healthy work environment we ask that team members complete this questionnaire before coming entering any company office/facility.



Yes No
Persistent dry cough, shortness of breath/difficulty breathing, fever (100.4¡ÆF or higher), sore throat, loss of taste or smell.
Which of the following symptoms have YOU experienced? Select Yes/No for all symptoms.
Yes No
Yes No
Yes No
Yes No
Yes No


Yes No
Persistent dry cough, shortness of breath/difficulty breathing, fever (100.4¡ÆF or higher), sore throat, loss of taste or smell.
Which of the following symptoms has a member in your household experienced? Select Yes/No for all symptoms.
Yes No
Yes No
Yes No
Yes No
Yes No


Yes No
**As defined by WHO, CDC - being within approximately 6 feet of an infected person for a total of 15 minutes or more in a 24 hour period or having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on, sharing utensils, or kissing someone confirmed to have been diagnosed with COVID-19).
Yes No
Yes No

CERTIFICATION

The information provided above is true and accurate to the best of my knowledge. I understand that failure to complete this certification each day that I report to a company facility, failure to accurately complete this certification to the best of my knowledge, and/or knowingly providing incorrect or false statements herein may result in taking appropriate action, including but not limited to sending me home until I am symptom-free and/or corrective action for violations of the certification requirements. I also authorize Company Name, LLC to retain this information if it is treated as confidential medical information.