Employee COVID-19​ Questionnaire and Health Screening Form

Prior to your shift
 Please complete this form prior to your scheduled shift.

Do you or anyone living in your household currently have any of the following symptoms:
Is anyone in your household currently under quarantine for a covid 19 related exposure or diagnosis?

©2020 Functional Kids Therapy. Proudly created by JPIXEL

BATTLE CREEK LOCATION

777 Goguac St W. Suite B2
Battle Creek, MI. 49015

Phone: ( 2 6 9 )  2 2 3 - 7 7 8 6
Fax: ( 2 6 9 )  9 6 2 - 9 5 6 9

  • Pinterest
  • Facebook - Black Circle
  • Instagram

CALEDONIA
 LOCATION

9809 Cherry Valley SE Suite D
Caledonia, MI. 49315

Phone: ( 6 1 6 ) 5 3 6 - 2 2 1 1 
 
Fax: ( 2 6 9 )  9 6 2 - 9 5 6 9

  • Pinterest
  • Facebook - Black Circle
  • Instagram

NOW
OPEN

403 North Grand Street
Schoolcraft, MI. 49087

Phone: ( 2 6 9 ) 3 0 0 - 7 3 93 
 
Fax: ( 2 6 9 )  2 2 5 - 0 1 0 5

  • Pinterest
  • Facebook - Black Circle
  • Instagram
FunctionalKids-Logo-MAIN.png
  • Facebook - Black Circle
  • Instagram
  • Pinterest