Mexico ABP COVID-19 Health Screening

Daily COVID-19 Self Health Screening

This pre-work Symptom Survey must be completed prior to reporting to work today. It is critically important that everyone working is healthy and symptom free. Please complete this brief survey.
Date *

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

First Name Last Name
Phone Number *
Plant Location *
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 *

Yes No
Vomiting/Diarrhea *

Yes No
Fever (37.5° C or higher) *

Yes No
Cough (not related to allergies) *

Yes No
Difficulty Breathing *

Yes No
Have you recently traveled outside of your city? *

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

Clear
Should be Empty:

Daily COVID-19 Self Health Screening