Online Health Assessment

Name*

First Last

Date*

Job Number

Project Location

Bodie Mechanical Reference*

Office
Field
Visitor
Subcontractor

Name

Company

Description of Symptoms (Within Last Seven Days)

In an effort to reduce the risk of coronavirus (COVID-19) exposure to employees, clients, visitors and community, all employees/subcontractors/visitors/etc. must complete the following Health Checklist BEFORE being allowed on our jobsite(s).

Have you been around someone who has been showing symptoms of COVID-19 and/or tested POSITIVE for COVID-19 within the past 14 days?*

Yes
No

Have you had a fever of 100.4 or more at any time in the last 48 hours?*

Yes
No

Are you feeling well today?*

Yes
No

If not, call HR immediately. DO NOT GO TO THE WORKSITE.

Please check if you have the following symptoms.*

Cough
Shortness of breath
Sore throat
Loss of taste/smell
Muscle aches
Trouble breathing
Chills
No symptoms

If you have three (3) or more of the symptoms, please leave IMMEDIATELY and contact HR.

Comments/Concerns

NOTE: Please continue to look for the weekly State of Ohio County Map that will be sent out with the toolbox talk. This Map is color coded for the level of risk per county for COVID-19. This map can also be viewed at https://coronavirus.ohio.gov/wps/portal/gov/covid-19/public-health-advisory-system/

Name

First Last