COVID19-Self Assessment

Please take this COVID-19 Self Assessment BEFORE coming into the office

The objective of this self-assessment is to keep our employees safe and protect FTG from liability.

"*" indicates required fields

Date*

Name*

First Last

FTG Company*

Email*

Have you had contact with or cared for anyone who has a confirmed or possible case of COVID-19 in the last 14 days?*

* If you answer "YES" to this question, DO NOT go to work and please call your Supervisor to inform them.

Yes

Do you experience or have any of the following?

A temperature of 100.4 degrees Fahrenheit or higher after taking your temperature in the last hour
A cough
Chills or repeated shaking chills
Muscle aches
A sore throat, have a loss of taste or smell
Nausea, vomiting or diarrhea

Self-Assessment/Acknowledgement*

* If you answer "I DO" to this question, DO NOT go to work and please call your Supervisor to inform them.

I DO experience 1 or more of the above symptoms

I DO NOT experience any of the above symptoms