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Please answer the following questions to the best of your ability. Please note that all questions are required. We appreciate your participation in helping our community combat the spread of COVID-19.

The information submitted through this form will be shared with your supervisor and ASM Global Human Resources. If you have any questions, please contact your supervisor.

No Symptoms
One or more of the following:
Fever (>100.4°F), chills, or sweating
Difficulty breathing
Cough
Sudden loss of taste and/or smell
Sore throat
Aching throughout the body
Vomiting or diarrhea

Yes
No
N/A

No Symptoms
One or more of the following:
Fever (>100.4°F), chills, or sweating
Difficulty breathing
Cough
Sudden loss of taste and/or smell
Sore throat
Aching throughout the body
Vomiting or diarrhea

No Symptoms
One or more of the following:
Fever (>100.4°F), chills, or sweating
Difficulty breathing
Cough
Sudden loss of taste and/or smell
Sore throat
Aching throughout the body
Vomiting or diarrhea

In the last 14 days, have you traveled outside your normal daily routine?

Yes
No

Yes

In the last 14 days, what is your exposure to others who are known to have COVID-19?

I live with someone who has COVID-19
I’ve had close contact with someone who has COVID-19
I’ve been near someone who has COVID-19
I’ve not had exposure

I live with someone who has COVID-19

I’ve had close contact with someone who has COVID-19

I’ve been near someone who has COVID-19

I’ve not had exposure

*I understand that by checking the box below I am confirming that I have answered all questions truthfully. I understand that if any of these answers change over the course of the next week I am required to notify my supervisor immediately.

I agree to the above statements.
*

Employee Health Questionnaire (6636)