COVID-19 Questionnaire - Tri-City Electric

The information collected on this form is confidential and intended solely for the use of our HR/Safety team. If you have any questions, please call 563-322-7181.

All fields are required.

Name:

Phone:

Select one of the following:

I am feeling ill or possibly experiencing COVID-19 symptoms. I have recently been exposed to someone who’s tested positive for COVID-19.

Do you have either a fever or loss of taste and/or smell?

Yes No

What date did your symptom(s) begin?

Please select from the following symptoms which you are currently experiencing:

Cough
Sore Throat
Body Aches
Headache
Runny Nose
Other

Is the COVID-positive person a member of your household?

Yes No

What date did the covid-positive person begin to develop symptoms or test positive? (If no symptoms and only a positive test, please use the test date. If person had symptoms, please use the first date of symptoms.)

Were you in contact with this person within the 48 hrs prior leading up to this date?

Yes No

Are you currently vaccinated for COVID-19? You do not have to answer if you wish not to. However, this may aid in determining the need to quarantine.

Yes No Prefer not to answer