COVID-19 Daily Questionnaire

Please fill out the following information for the project you are working on. This form is to be filled out daily by all contractors working on a job-site. If you have answered YES to any of these questions you should not be working on this job-site and must leave immediately and seek medical attention or quarantine per CDC guidelines.




1. Have you come into close contact (within 6’) with someone who has a confirmed COVID-19 diagnosis within the past 14 days?YesNo


2. Do you have/have had any of the following symptoms within the past 14 days:?

- A fever greater than 100.3º FYesNo
- CoughYesNo
- Shortness of BreathYesNo
- Difficulty BreathingYesNo
- Sore ThroatYesNo


3. Have you been asked to self-isolate or quarantine by a doctor or a local public health official?YesNo


4. Do your planned work activities today require performance of tasks without PPE in close contact with another worker?YesNo


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