COVID-19: Fit for Duty Questionnaire

To prevent the spread of the novel coronavirus (COVID-19) in our community and reduce the risk of exposure within our workplace, each employee of Active Interested Media is required to complete this questionnaire daily before entering an office.

Employee

Vendor/Contractor

Visitor

Full Name*

Supervisor/Manager

Contact Name

Who are you visiting

Office Location*

Self-Declaration by Employee

Are you currently, or have you in the past 72 hours, exhibited any of the following symptoms that cannot be attributed to a health condition other than the possibility of COVID-19? (Check all that apply.)

Fever

Cough

Shortness of breath

Chills

Repeated shaking with chills

New loss of taste or smell

In the past seven days, have you traveled by commercial plane?

In the last 14 days, has anyone in your household been confirmed or suspected of being infected with COVID-19?

Being within approximately six feet of a COVID-19 case for longer than two minutes.
Having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on).

In the past 14 days...

to your knowledge, have you had close contact with anyone who has been confirmed to have COVID-19?

have you traveled outside of the country?

have you traveled by cruise ship?

“By electronically signing below, I hereby certify the above information to be true and correct to the best of my knowledge.”

Employee Signature:*