COVID-19 Team Member Screening

COVID-19 Team Member Screening
Date *

Month Day Year
Date Hour Minutes AM/PM Option
Name *

First Name Last Name
Email *
example@example.com
Division *
What is your current temperature? *

Do you have any of the following symptoms? *

Yes

No

Fever over 99.5, cough, chills, or shortness of breath

Have you had exposure to someone with, or under investigation for COVID-19 that has not been discussed or cleared by leadership??

Please contact one of the following to discuss your symptoms indicated above before continuing your shift:

Scott Sigerfoos: 574-551-6236

Tony Doyle: 574-551-8872

Pat Unger: 260-388-8013
Should be Empty: