Online Health Assessment Name* First Last Date* Date Format: MM slash DD slash YYYY Job NumberProject LocationCompany Name*ACIATIVisitorSubcontractorCompanySubcontractor NameDescription 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).Are you feeling well today?*YesNoDid you take your temperature today?*YesNoWhat was your temperature (degrees F) before coming to work?If temperature is 100.4 degrees F or higher, IMMEDIATELY NOTIFY HR.Have you been to a Level 3 (RED) or Level 4 (PURPLE) area in the State of Ohio?*YesNoIf yes, what county/counties?Have you been around someone who has been showing symptoms of COVID-19 within the past 14 days?*YesNoHave you been around someone who has tested positive for COVID-19 within the past 14 days?*YesN0Have you traveled outside the State of Ohio or out of the country?*YesNoIf yes, when and where?Please check if you have the following symptoms.* Cough Shortness of break 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:
