COVID-19 JOBSITE SCREENING QUESTIONNAIRE

 

In response to the recent Coronavirus (COVID-19) outbreak and the raised pandemic alert by the World Health Organization (WHO) as well as State and Federal Governments, WENRICH PD Construction, LLC (“WENRICH”) is taking precautions to lessen the spread of the virus. All individuals who enter any jobsite by request of WENRICH and where WENRICH is a subcontractor or acting General Contractor jobsite must be initially screened and responsible to report any changes to the question response in the future before re-entering the site in the future.

 

Please answer the following questions for the safety of yourself and others. If you are a WENRICH on site staff, crew person, 2nd tier subcontractor or visitor to the jobsite for the first time today:

Within the past 14 days have any persons returned from, or been exposed to anyone who returned from, a Level 3 location designated by the Centers for Disease Control (“CDC”)?

*Please check the CDC website for Level 3 designations as such designations change from time to time.

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Within the past 14 days have any persons utilized domestic air travel?

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Have any persons been diagnosed with COVID-19 or been exposed* to someone who has been diagnosed with COVID-19 within the fourteen (14) days prior to the person’s diagnosis?

*A person has been “exposed” to someone diagnosed with COVID-19 if:

  1. They were a member of the household of the diagnosed individual or providing care to them in their household

  2. They were their intimate partner

  3. They had close contact (less than 6 feet) with the infected person)

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Have any persons experienced or been exposed to anyone that is currently experiencing a fever of 100.4 F or higher, cough or shortness of breath, difficulty breathing, sore throat, loss of taste or smell, chills, or vomiting/diarrhea in the last 24 hours?

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The information provided on this questionnaire will be treated as confidential by WENRICH. It will only be reviewed by WENRICH personnel as needed to manage site safety protocols and will not be shared with anyone outside of WENRICH without consent unless required by state or federal law or regulatory authorities.

 

By signing below, I certify I have reviewed the above questions with all the personnel listed below and all of the foregoing statements are true and correct, and I agree that if any of the above answers change, I will notify the WENRICH management immediately. In addition, I represent and warrant that the company identified below will remain compliant with the WENRICH Jobsite COVID-19 Policy.