Name *

First Name

Last Name

Phone *

(###)

###

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Do you live in the same household with, or have you had close contact with someone who in the past 14 days was diagnosed with COVID-19 or had a test confirming they have the virus? Check One: *

Yes

No

CheckboxWithin the last 10 days have you been diagnosed with COVID-19 or had a test confirming you have the virus? Check One:1 *

Yes

no

Have you had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by a pre-existing condition? • Fever of 100.4 ̊ or greater, Chills, or Repeated Shaking/Shivering • Cough • Sore Throat • Shortness of Breath, Difficulty Breathing • Feeling Unusually Weak or Fatigued • Loss of Taste or Smell • Muscle Pain • Headache • Runny or Congested Nose • Diarrhea • Check One: *

Yes

No

Have you traveled internationally within the past 14 days (please answer 'Yes' or 'No')? If yes, please list where? *

Yes

No

By checking 'Yes' below I attest that my answers above are accurate to the best of my knowledge. *

Yes

By checking 'Yes' below I affirm I will notify FX Group if there are any changes to my answers that occur after I complete this form, and before I arrive to the work location. *

Yes

The information in the questionnaire(s) or any report generated from information contained in the questionnaire(s) is the sole property of the Employer. Any designated person that would need to be furnished with this information to carry out their duties must return the information to the Employer and may not retain the information. *

I Agree

I’ve received and reviewed the COVID-19 General Safety Practices. I understand the fundamentals of hygiene as well as the use and maintenance of PPE, and to this end, I have reviewed any information provided, including the videos below on this page. . Nothing contained herein is intended to revoke or repeal any employee rights, either statutory, regulatory, or collectively bargained, and are not exhaustive. Nor are they a substitute for any existing safety and health-related regulatory requirements. *

Yes - I acknowledge the above and have viewed each of the four videos below.