COVID-19 Screening

This daily screening is required on all R.C. Hendrick & Son jobsites. Please note that if an employee answered "yes" to any of the screening questions below, the employee is not permitted on the work site and should self-isolate/self-quarantine at home.
Name: Name: * First Last
Company Name: *
Date Date * / MM / DD YYYY
Jobsite Name: *
Have you been in close contact with anyone diagnosed with COVID-19 in the last 14 days? *

Have you been in close contact with anyone diagnosed with COVID-19 in the last 14 days? Yes No
Have you experienced any symptoms of fever, cough, shortness of breath, sore throat, or diarrhea? *

Have you experienced any symptoms of fever, cough, shortness of breath, sore throat, or diarrhea? Yes No
I certify that the above information is accurate to the best of my knowledge. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.