COVID-19 On-Site Employee Visit In an effort to reduce the risk of COVID-19 exposure to McKonly & Asbury employees, all clients must complete the following questionnaire in advance of an on-site employee visit. Health Screening Form Date MM slash DD slash YYYY Company Name:* Company Representative Name/Title:* Company Representative Phone Number:* Is your Company monitoring state and local public health communications about COVID-19?*YesNoDo you encourage sick workers to report symptoms, stay home and follow CDC guidance?*YesNoIs your Company encouraging social distancing and use of cloth face coverings for both employees and visitors?*YesNoIs your Company cleaning and disinfecting frequently touched surfaces?*YesNoHas anyone in your Company been diagnosed with COVID-19 in the past 14 days?*YesNoAnswering ‘no’ to any of the first four (4) questions, or ‘yes’ to the fifth (5th) question, may limit our ability to be on-site at your Company’s facility. Please inform us prior to an on-site visit if your answers to any of these questions have changed. Company Representative Signature (please type): McKonly & Asbury Professional: CAPTCHAEmailThis field is for validation purposes and should be left unchanged.