COVID Declaration Formadmin2022-02-01T15:23:42+04:00 Visitor Name Date Company Phone Bechtel Point of Contact Purpose of Visit AMI is concerned for the safety and health of all employees and visitors. As we are closely monitoring the current COVID-19 pandemic and in the interest of ensuring a safe and healthful work environment, we are asking all visitors to complete this brief questionnaire 1. Have you been diagnosed as having COVID-19 within the last 14 days? YesNo 2. Have you had a potential exposure to COVID-19 (e.g., being a household contact or having close contact within 6 feet of an individual with confirmed or suspected COVID-19) within the last 14 days? YesNo 3. Are you currently experiencing or have experienced any of the following COVID19 symptoms within the last 14 days? If yes, check all that apply: Cough; orShortness of breath or difficulty breathing; orFever; orChills; orMuscle Pain; orSore Throat; orNew loss of taste or smell; orGastrointestinal symptoms like nausea,vomiting, or diarrhea By my signature below I confirm that the above information is true and correct and agree to follow all precautionary measures required by the workplace, which may include, but is not limited to: * Avoiding personal greetings (e.g., handshakes) that involve bodily contact with others * Maintaining 6 feet social distancing from others * Use of a disposable face mask or cloth face covering * Practicing respiratory etiquette, including covering coughs and sneezes * Practicing frequent handwashing * Participating in temperature screening
