Town of Orchard Park

Covid19 Questionnaire

Covid19 Questionnaire

EMPLOYEE & VISITOR COVID-19 SCREENING QUESTIONNAIRE
The safety of our employees and visitors is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire to their manager/supervisor prior to beginning work and immediately after swiping/signing in daily. Visitors should hand it in to the assigned person within each department.
Please respond to each of the following questions truthfully and to the best of your ability.
Your participation is important to help us take precautionary measures to protect you and all employees.
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1. Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms?
NOTE: Information provided on this form will only be used to determine if you may be infected with COVID-19. This information will be maintained as confidential. Questions should be directed to a manager or our human resources representative.