COVID-19 Health Screening Questionnaire for Employees

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To prevent the spread of novel coronavirus (COVID-19) in our community and reduce the risk of exposure to our staff and visitors, we are conducting a simple screening questionnaire based on guidance from the Centers for Disease Control and Prevention (CDC). Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your understanding and time. This form will be kept confidential.

This process should take no more than 45 seconds. If the process takes longer, or if you experience technical difficulties, please inform your supervisor.

Upon form submission, you will receive an email with further instruction.

Your name *

Your preferred email address *

This is the email address your access pass will be sent to

Your G4S Office Branch Code *

What customer site are you scheduled to work at? Please provide our customer's business name.

Last 4 digits of your SSN *

City of Residence *

State of Residence *

Have you been diagnosed with a case of coronavirus (COVID-19) in the last 14 days?

Within the past 14 days, have you had close contact with anyone that you know had COVID-19 or COVID-like symptoms? Close Contact is within 6 feet of an Covid-19 infected person for a total of 15 minutes in a 24-hour period, or having direct contact with fluids from a person with COVID-19 (for example, being coughed or sneezed on).

Have you or any member of your household been directed to self-quarantine by any health care provider or health agency in the last 14 days?

In the past 24 hours, have you experienced any of the following symptoms (that you cannot attribute to another health condition)?

Have you had a fever (100.0℉ or higher) within the past 24 hours?

Are you currently awaiting the results of a COVID-19 test that was taken due to being symptomatic or potential exposure?

I attest to the following (select one of the following): *

I can answer "no" to all of the above questions and I am able to safely report to work as scheduled.

I have answered "yes" to at least one of the questions above, and understand that I am not permitted to report to work at this time. I will notify my supervisor in accordance with established call-off procedures.

FM-501e (10/05/2020) This document is proprietary to G4S Secure Solutions (USA) Inc.

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