Name:______________________________________________________ Email: _______________________________
Date: ___________________ Phone #: ___________________
Altru Contact:
Name: _________________________ Phone #:_____________________ Job Title/Position: _____________________
Have you traveled in the past 14 days? ...................................................................................................... Yes No
If yes, please list:
Destinations:
Mode of travel:
Dates of travel: ___________________ ___________________ ___________________
Have you incorporated social distancing while required to be in public?...................................................... Yes No
To the best of your knowledge, have you had any contact with anyone with confirmed
or suspected Coronavirus (COVID-19) infection? ........................................................................................ Yes No
Date(s) of exposure/close contact with known or suspected Coronavirus infected person:
Please indicate if you have had any of the following symptoms:
Cough or other cold or flu-like symptoms .................................................................................................... Yes No
Fever.............................................................................................................................................................. Yes No
Shortness of breath ...................................................................................................................................... Yes No
Loss of taste/smell ........................................................................................................................................ Yes No
I understand that I have the responsibility to immediately notify employee health AND my immediate supervisor/leader
should my responses on this questionnaire change.
Signature __________________________________________________________________ Date: ________________
