PLF/JBT COVID-19 Employee - Pre-Site - Attendance -Self Assessment

• Employee Name

• If an employee answers “Yes” to any of the screening questions, immediately activate your company’s emergency protocol.

Employee Pre Site Attendance

• 1. Have you or someone in your household or workplace been in close contact with a person who has signs of or has COVID-19?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• 2. Have you been medically directed to self-quarantine?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• 3. In the last 72 hours, have you had: a new fever of 100.4°F, a new cough, shortness of breath, sore throat, new muscle aches or a loss of taste or smell?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• 4. Are you feeling unwell and deem yourself as potentially contagious

  Select Yes No N/A

  • Yes
  • No
  • N/A

• If you have answered yes to questions 1 to 3 Stay at home, do not attend site. Call your line manager as per the employee handbook and report sick. If the symptoms are COVID-19 related book a test immediately .

• If you have answered yes to question 4 . Stay at home do not attend site. Call line manager as per the employee handbook and report sick.

• Select date

  Date

• Add signature

  Sign