COVID-19 Questionnaire

In compliance with MIOSHA and the Center for Disease Control recommendations, all employees must complete a COVID-19 screening questionnaire as detailed below. Failure to comply will be deemed as non-compliance and a failed screening. This will also result in loss of pay, and additional disciplinary actions may apply.

The screening questions must be answered. Check your response.

Your answers to the following questions are REQUIRED DAILY:


Do you have any of the following symptoms including but not limited to:
  • Fever of 100.1 degrees or higher (as measured by a touchless thermometer if available) but a verbal  confirmation of lack of fever is sufficient if a touchless thermometer in not available); or
  • Cough (excluding cough due to a known medical reason other than COVID-19); or
  • Shortness of breath; or
  • At least 2 of the following symptoms: repeated shaking with chills, muscle pain, headache, sore throat, new loss of taste or smell, and/or diarrhea (excluding diarrhea due to a known medical reason) , and extreme fatigue? 
YES        NO
Have you had any contact (close contract being <6 feet for >15 minutes) in the last 14 days with someone with a diagnosis of COVID-19?
YES        NO
Have you traveled internationally in the last 14 days?
YES        NO
Full Name (First & Last):