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.

Date*
MM slash DD slash YYYY
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
- No
Do you experience or have any of the following?
1. A temperature of 100.4 degrees Fahrenheit or higher after taking your temperature in the last hour
2. A cough
3. Chills or repeated shaking chills
4. Muscle aches
5. A sore throat, have a loss of taste or smell
6. 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