Daily COVID-19 Employee Infection Control Questionnaire "*" indicates required fields Name First Last 1. Are you currently experiencing any of the following COVID-19 related symptoms, WITH AN UNKNOWN CAUSE (eg, not due to asthma, chronic sinusitis, COPD, etc)* Yes - Cough Yes - Shortness of breath or difficulty breathing Yes - Sore throat Yes - New loss of taste or smell Yes - Chills Yes - Head or muscle aches Yes - Nausea, diarrhea, vomiting No for all 2. In the past 14 days, have you been near anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?* Yes No 3. Have you been in contact with anyone who has tested positive for COVID-19 in the last 14 days?* Yes No 3a. Any additional information you would like us to know?4. In the past 14 days, have you traveled out of the United States, or been in contact with anyone who has* Yes No 5. Are you taking any medication to reduce a fever?* Yes No It is expected that you understand these questions and stay home if any of these answers are “Yes”, DO NOT REPORT TO WORK. Contact your health care provider and Cristy Stedl in Human Resources at 920-418-4056 or cstedl@medalcraft.com. If all the above are “No”, please stand in front of the HAVIRON Thermal Unit for your temperature to be taken, if your temperature is 100.4 or higher, you will not be allowed into the building. Please go to your vehicle and wait for 30 min and come back and retest. If still high, please leave and contact your health care provider and Cristy Stedl. If cleared, please then turn this form in to your manager or HR. CERTIFICATION I hereby certify that the responses provided above are true and accurate to the best of my knowledge.Electronic Signature* Please enter your full nameNote: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential. Any questions should be directed to your manager or HR. CAPTCHA