In accordance with our Safety Policy, we thank you for your cooperation in completing this form. To gain access to Holland Engineering’s (“Company”) worksite(s):

Do you have, or have you had in the last two (2) days, any principal symptoms of COVID-19? Unless defined otherwise by the Michigan Department of Health and Human Services, “principal symptoms of COVID-19” include:

Any of the following:

Fever (of at least 100.4 degrees);
Uncontrolled Cough;
Atypical New Shortness of Breath;

OR

At least two of the following not explained by a known physical condition:

Sore Throat;
Vomiting;
Diarrhea;
Muscle Pain;
Severe Headache;
New Loss of Taste or Smell;
Abdominal Pain.

Please answer Yes or No

Yes No

Have you had close contact with someone displaying symptoms of or diagnosed with COVID-19? Unless defined otherwise by the Centers for Disease Control and Prevention, “close contact” means: (a) you have been within six feet of a person confirmed to have or displaying principal symptoms of COVID 19, irrespective of whether you or the other person was wearing a mask; (b) your contact with the person was for a cumulative total of 15 minutes or more; and (c) your cumulative 15-minute contact was over a 24-hour period that starts from two days before the person’s illness onset (or, for asymptomatic persons, two days prior to test specimen collection) and lasts until the time the person is isolated:

Please answer Yes or No

Yes No

Any individual who answers “Yes” to any of the foregoing questions will be refused entry to the Company’s worksite(s) and asked to return no earlier than the following schedule:

Individuals who display principal COVID-19 symptoms or are confirmed to have COVID-19 may return after:

24 hours with no fever (without the use of fever-reducing medication);
Ten days since the first appearance of symptoms (or since the test specimen collection for asymptomatic persons); and
An improvement in other symptoms.

Individuals who have had close contact with a person confirmed to have or displaying principal symptoms of COVID-19 may return after 14 days since the last date of close contact with the potentially infectious person. If an employee or contractor has only had close contact with a symptomatic person, and it is later determined that the symptomatic person does not have COVID-19, the employee or contractor may discontinue his or her 14-day quarantine.

The Company will maintain a record of all daily employee health screenings as required by MiOSHA’s Emergency Rules for COVID-19. All such records will be held strictly confidential and disclosed only to the extent required or allowed by law.

ACKNOWLEDGEMENT

First Name

Last Name

Email Address

Phone Number

I have read the screening questions above and have provided truthful answers. I understand that the intentional falsification of this questionnaire may result in appropriate disciplinary action or may impact my ability to provide services to the Company. I further understand that the Company will deny me entry to the Company’s worksite(s) if I fail to complete this questionnaire. I recognize that if I have any questions regarding the screening questions above, I can ask a manager or supervisor, or I can contact the Human Resources Department.

Today’s Date