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COVID-19 Self Health Screening
This daily Symptom Survey must be completed prior to visiting ANY of our locations. It is critically important that everyone working is healthy and symptom free. Please complete this brief survey.
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AM/PM Option
Name
*
First Name
Last Name
Phone Number
*
Company Name
*
Facility you are visiting
*
Plant 1 30905 23 Mile Road
Plant 2 30871 23 Mile Road
Plant 4 50900 E. Russell Schmidt
Plant 5 50625 Richard W. Blvd.
Health Questions
Are you currently experiencing any of these symptoms or have you experienced any of these symptoms in the last 14 days? **If you answer yes to any of these questions, please speak with your Manager.
Sore Throat (not related to allergies)
*
Yes
No
Vomiting/Diarrhea
*
Yes
No
Fever (100.4F or higher)
*
Yes
No
Cough (not related to allergies)
*
Yes
No
Difficulty Breathing
*
Yes
No
Have you recently traveled outside of Michigan?
*
Yes
No
Have you been in close contact with someone with a confirmed diagnosis of COVID-19 or is being tested for COVID-19?
*
Yes
No
Have you traveled or been in contact with someone who traveled by airplane internationally or domestically and / or been aboard any cruise ship in the last 14 days?
Yes
No
Signature
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