JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Usher Tool and Die COVID-19 Screening
Please complete this form before arriving to your work area. If you answer "Yes" to any of the following questions, please do not enter the building.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Name
*
Your answer
Are you experiencing any of the following symptoms: Fever, cough or shortness of breath, sore throat, chills, muscle aches or rigors, headache, new loss of taste or smell, abdominal pain, nausea, vomiting or diarrhea?
*
Yes
No
Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?
*
Yes
No
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
*
Yes
No
Are you currently waiting on the results of a COVID-19 test?
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Usher Tool and Die, Inc..
Report Abuse
Forms
