Online Health Assessment Name* First Last Date* MM slash DD slash YYYY Job Number Project Location Company Name* ACI ATI Visitor Subcontractor Company Subcontractor Name Description of Symptoms (Within Last Seven Days)In an effort to reduce the risk of coronavirus (COVID-19) exposure to employees, clients, visitors and community, all employees/subcontractors/visitors/etc. must complete the following Health Checklist BEFORE being allowed on our jobsite(s).Have you been around someone who has been showing the symptoms of COVID-19 and/or has tested POSITIVE for COVID-19 within the past 14 days?* Yes No Have you had a fever of 100.4 or more at any time in the last 48 hours?* Yes No Are you feeling well today?* Yes No If not, call HR immediately, DO NOT GO TO THE WORKSITE. Please check if you have the following symptoms.* Cough Shortness of breath Sore throat Loss of taste/smell Muscle aches Trouble breathing Chills No symptoms If you have three (3) or more of the symptoms, please leave IMMEDIATELY and contact HR.Comments/ConcernsNOTE: Please continue to look for the weekly State of Ohio County Map that will be sent out with the toolbox talk. This Map is color coded for the level of risk per county for COVID-19. This map can also be viewed at https://coronavirus.ohio.gov/wps/portal/gov/covid-19/public-health-advisory-system/Name* First Last Companies of Kirk Corporation include:
