COVID-19 COVID-19 Return to Work Questionnaire Please fill the following questionnaire prior to coming into Halla Mechatronics. (Last updated: May 13, 2020) The safety of our team members, supplier partners, customers, families, and visitors remain top priority. As the Corona Virus Disease 2019 (COVID-19) outbreak continues to evolve and spread globally, Management (locally and globally) are monitoring the situation closely and will periodically update company guidance based on current recommendations from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). Only business critical visitors are permitted at our facility at this time. To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is required to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.Name*Please enter your name First Last Supervisor*Please select your supervisor-- Supervisor List --Kevin RossTony DodakTed SeegerTomy SebastianChristian RossScott WendlingTroy StrieterJeremy BreaultRamakrishnan RajaDheeraj PatelShakil HossainDavid SaphRich EllisonMohammad IslamNeil MonizAmy HollowayCompany Name (if applicable)Please enter your company name Self-DeclarationAfter testing yourself for fever TODAY, is your temperature over 100.4 degrees?* Yes No Since your last clearance to work in the office, have you tested positive for COVID-19?* Yes No Have you travelled internationally in the last 14 days?* Yes No If yes, where? Have you been in contact with anyone who works with OR exposed to COVID-19 in the last 30 days that has not been previously reported to your Supervisor/Manager?* Yes No Have you been exposed to anyone in the last 14 days that tested positive for COVID-19?* Yes No Have you been exposed to anyone that has experienced a fever, chills (shaking with chills), muscle pain, headache, sore throat, cough, difficulty breathing, loss of taste or smell in the last 14 days?** Yes No Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, chills (shaking with chills), muscle pain, headache, soar throat, cough, difficulty breathing, loss of taste or smell)?* Yes No If the answer is "yes" to any of the questions, you must report to your supervisor for review before being allowed to report for work.HiddenDate* MM slash DD slash YYYY Consent*** Consent Agreement Here. I agree to the above response is acurate to the best of my knowledge.NameThis field is for validation purposes and should be left unchanged.
