COVID Form test Page

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The CDC and Department of Health for the states of Minnesota, Illinois, California, and Washington ask that employers use this guidance to prevent the spread of COVID-19 in the workplace by screening employees daily.

First Name

Last Name

Division

Location

Please keep track of your daily recorded temperature by using the 'Temperature Activity Log' found on tnet.

By selecting ‘Yes’ in response to the symptom statements below, you are advised to stay home and/or telework if you are able. If you are experiencing any COVID-19 related symptoms, Human Resources will contact you to provide you with further guidance.

In the past 24 hours, have you experienced any signs or symptoms of a fever such as chills or sweats, or recorded a temperature of 100.0º F or greater?

Yes
No

In the past 24 hours, have you experienced any of the following COVID-19 related symptoms that cannot be attributed to another known health condition?

Cough

Yes
No

Shortness of Breath

Yes
No

Body Aches / Muscle Pain

Yes
No

Loss of Taste and/or Smell

Yes
No

Within the past 14 days, have you been sharing a personal space or been in contact with someone with a confirmed diagnosis of COVID-19?

Yes
No

Within the past 14 days, have you or someone you have been in close contact with traveled to a high risk location (domestic or international)?

Yes
No

Comments, Concerns, or Questions

Add any comments, concerns, or questions you may have.

Health Questionnaire Acknowledgements:*

I acknowledge that I will not enter the workplace (office or project site) if I am sick.
I acknowledge that if my responses indicate that I may have symptoms consistent with COVID-19, I will not enter the workplace (office or project site) until I have discussed my condition with Human Resources and my manager and outlined an appropriate course of action.
I acknowledge that I will remove myself from the workplace (office or project site) if I develop or display any symptoms consistent with COVID-19 after submitting my responses. I also acknowledge that I will notify Human Resources immediately for further guidance.
I agree to abide by TKDA’s guidelines and protocols for social distancing, use of face coverings, sanitization / disinfection, and personal hygiene.
I certify all the information in this submittal is true and accurate to the best of my knowledge.

Today's Date*