Page 434 - Safety Memo

Health Assessment (COVID-19)

Employee Name
Company
Project # Project Name

Recorded Temperature
o
(Normal temperature is 98.6 F)

Assessment Criteria YES NO
1. Did/does the employee have any of the following symptoms
a. Fever  
b. Sore Throat  
c. Cough  
d. Shortness of breath  
2. Has the employee been in contact with someone showing symptoms  
of COVID-19?
3. Has the employee been in contact with someone tested positive for  
COVID-19?

If the employee answered “YES” to any of the questions above, they must inform
their supervisor and leave the jobsite immediately. Employee shall contact their
health care provider to determine if COVID-19 testing is needed.

Employee Signature: _____________________________ Date: ________________