This questionnaire is to be completed daily by R2T staff and visitors BEFORE entering an office, jobsite/construction site, or doing any fieldwork activities.
Your Email (required)
Today's Date (required)
If a temperature reading is required by client, insert your current temperature. (required) Insert N/A if not required.
1. Project Assigned To (Select All that Apply): (required) QuarlesSeacoastOfficesCA and Field Services - R2T
2. Enter your specific site location below. (required) If you are going to more than one location, please enter all locations. (Example: I'm going to the office and then to the field)
3. Your Name (required)
4. Have you or anyone in your family been in contact with a person that has tested positive for COVID-19? Select Yes or No. YesNo
5. Have you or any of your family been in contact with a person that is in the process of being tested for COVID-19? Select Yes or No. YesNo
6. Have you or any of your family traveled outside the USA in the past 14 days? Select Yes or No. YesNo
7. Have you been medically directed to self-quarantine due to possible exposure to COVID-19? Select Yes or No. YesNo
8. Are you currently having trouble breathing or have any flu-like symptoms in the past 48 hours? Including, fever, cough, shortness of breath, sore throat, runny or stuffy nose, body aches, muscle pain, headache, loss of taste or smell, chills, repeated shaking with chills or fatigue. Select Yes or No. YesNo
9. Are you currently free of and have been free of fever (100 degrees F or 37.8 degrees C) or signs of a fever without the use of fever-reducing medications for at least 24 hours? Select Yes or No. YesNo
PPE Equipment Checklist: MaskGlovesFace Shield (if applicable)Hand Sanitizer/Wash Station
IF YES IS ANSWERED TO QUESTIONS 4 - 8, NO TO QUESTION 9, OR YOU DON'T HAVE THE REQUIRED PPE, YOU ARE NOT ALLOWED TO ENTER THE JOBSITE/CONSTRUCTION SITE, OFFICE, OR YOU SHOULD NOT PROCEED WITH THE FIELD ACTIVITY.
