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 MonizCompany Name (if applicable)Please enter your company nameSelf-DeclarationAfter testing yourself for fever TODAY, is your temperature over 100.4 degrees?*YesNoWhile you were working from home, did you test positive for COVID-19?*YesNoHave you travelled in the last 14 days?*YesNoIf yes, where?Have you been in contact with anyone who works with OR exposed to COVID-19 in the last 30 days?*YesNoHave you been exposed to anyone in the last 14 days that tested positive for COVID-19?*YesNoHave you had a fever, chills (shaking with chills), muscle pain, headache, sore throat, cough, difficulty breathing, loss of taste or smell in the last 14 days?*YesNoHave 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)?*YesNoIf the answer is "yes" to any of the questions, you must report to your supervisor for review before being allowed to report for work.Date* Date Format: 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.