(269) 223-7786

Employee COVID-19 Questionnaire and Health Screening Form

Do you or anyone living in your household currently have any of the following symptoms:

Fever (temperature over 99.5)

Cough/ shortness of breath

Sore throat

Runny nose

Headache

Loss of taste/ smell

Extreme fatigue

None

Is anyone in your household currently under quarantine for a covid 19 related exposure or diagnosis?

Yes

No

I acknowedge that the information I have provided is accurate and up to date.

I accept terms & conditions

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

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

403 North Grand Street
Schoolcraft, MI. 49087

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

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