BOSH RTW Screening Form

BOS HOLDINGS RTW EMPLOYEE SCREENING QUESTIONNAIRE

To be completed by all BOSH Employees prior to returning to the office.
The safety of our members and their families, customers, suppliers, and visitors is always a key priority at BOSH. As the Coronavirus disease 2019 (COVID-19) outbreak continues to spread globally, BOSH is constantly monitoring the ever-changing situation and updating BOSH guidance based on current recommendations from the Center for Disease Control and the World Health Organization.

To prevent the spread of COVID-19 and to reduce potential exposure risk to your BOSH members and visitors, BOSH is using a simple screening questionnaire. Your participation is crucial to help BOSH protect you and everyone at a BOSH facility. Thank you for your time.
Employee Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Company
BOSH Supervisor Name:

First NameLast Name
Return to Office Date

MonthDayYear
Date
Reason for Coming In
EMPLOYEE SELF DECLARATION

(please circle the applicable response)
YesNo
YesNo
If your answer to any of the questions above is “yes,” we ask that you alter your return date plans to a BOSH facility and continue to work remotely until you can reschedule a future return date when your risk of exposure and transmission within the BOSH facility has been eliminated.
YesNo
What was the date and are you currently showing symptoms?
YesNo
What was the date of the first vaccine and the second?
Employee Signature

Clear
Note: If any of your responses change after submitting this form, please immediately inform your BOSH Supervisor.
Should be Empty:

BOS HOLDINGS RTW EMPLOYEE SCREENING QUESTIONNAIRE

EMPLOYEE SELF DECLARATION