COVID-19 Safety

COVID-19 Daily Health Check Questionairre

The safety and health of Fontanesi & Kann Company employees, subcontractors, and site visitors are of primary concern. As the COVID-19 virus continues to spread, we will continue to closely monitor the situation and provide updates on recommendations from the Center for Disease Control (CDC), OSHA, and MIOSHA.

To prevent the spread and risk of COVID-19 spread at the jobsite, we are administering this health check questionnaire. It is required by law that we keep daily checklists per employee and per jobsite. Please select all jobsites that you plan to visit today. Participation in this questionnaire is mandatory. Thank you for your cooperation.

Name *

First

Last

Company *

Phone *

Select Jobsite #1 *

Select Jobsite #2

Select Jobsite #3

Date / Time *

Date

Time

Screening Questions

Please complete the following questions honestly and accurately by selecting "YES" or "NO".

Have you traveled internationally within the last 14 days? *

Yes
No

Has someone you have close contact with traveled internationally within the last 14 days? *

Yes
No

Have you been in contact with a person showing symptoms of COVID-19 within the past 14 days? *

Yes
No

Have you been in contact with a person who has tested positive for COVID-19 within the past 14 days? *

Yes
No

Have you experienced any cold or flu-like symptoms in the last 14 days (fever, cough, sore throat, diarrhea, respiratory illness, or difficult breathing)? *

Yes
No

Signature

In compliance with Oakland County order, if you answered "YES" to any of the above questions, we are required to exclude you from entry into our facility and jobsites. This form will stay on file until the above information changes and a Return to Work form is completed.

I hereby acknowledge the above information to be true and correct. I also understand that any willful dishonesty will render for refusal of entrance to this facility.

Authorized Electronic Signature *

I understand by checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.

By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature.

COVID-19 Daily Health Check Questionairre

Screening Questions

Signature

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