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Project Site Check In
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Check in to your recent location '
' as '
'.
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Today’s Date and Time
:
Location ID
*
Location
*
Location Description (optional)
Employee or Visitor Name
First Name
*
Last Name
*
Employee or Visitor Contact Information
City
*
State
*
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*
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COVID-19 Questionnaire
All questions must be answered to submit the form.
PLEASE ANSWER ALL QUESTIONS BELOW
1. Do you have any of the following symptoms?
1a. Persistent cough
*
No
Yes
Based on your response, you are temporarily denied entry to Miron's project site. Please depart the premises immediately. We welcome you back once you are symptom-free
1b. Difficulty breathing
*
No
Yes
Based on your response, you are temporarily denied entry to Miron's project site. Please depart the premises immediately. We welcome you back once you are symptom-free
1c. Fever
*
No
Yes
Based on your response, you are temporarily denied entry to Miron's project site. Please depart the premises immediately. We welcome you back once you are symptom-free
1d. Chills/shaking
*
No
Yes
Based on your response, you are temporarily denied entry to Miron's project site. Please depart the premises immediately. We welcome you back once you are symptom-free
1e. Loss of taste or smell
*
No
Yes
Based on your response, you are temporarily denied entry to Miron's project site. Please depart the premises immediately. We welcome you back once you are symptom-free
2. In the last 14 days, have you had personal close contact with (live with, provide direct care for or been within six feet of for more than 15 minutes) anyone who is known to have COVID-19, suspected to have COVID-19, or is awaiting COVID-19 test results?
*
No
Yes
2a. Has the individual been fever-free for at least 72 hours (three full days of no fever without the use of fever-reducing medicine)?
No
Yes
Based on your response, you are temporarily denied entry to Miron's project site. Please depart the premises immediately. We welcome you back once you are symptom-free
2b. Have all symptoms (cough, shortness of breath, etc.) improved?
No
Yes
Based on your response, you are temporarily denied entry to Miron's project site. Please depart the premises immediately. We welcome you back once you are symptom-free
2c. Have at least seven days passed since their symptoms occurred?
No
Yes
Based on your response, you are temporarily denied entry to Miron's project site. Please depart the premises immediately. We welcome you back once you are symptom-free
3. Have you traveled internationally in the past 14 days?
*
No
Yes
3a. If you have traveled internationally in the past 14 days, where have you traveled?
3b. If you have traveled internationally in the past 14 days, what was the date of your return to the United States?
4. Have you tested positive for COVID-19, been told by a medical professional that you have had COVID-19, or are you awaiting pending results of a COVID-19 test?
*
No
Yes
4a. Have you completed your 10-day isolation period and have you been fever-free for 72 hours without the use of fever-reducing medication?
No
Yes
Based on your response, you are temporarily denied entry to Miron's project site. Please depart the premises immediately. We welcome you back once you are symptom-free
Date Signed
Email (optional)
example@example.com
Submit