The safety of all Insert Company Name employees, subcontractor employees and owner employees is our top priority. To ensure the safety of everyone, please complete the following form prior to working. In continuing to work, it is our intention to honor and follow, to the best of our ability, the health and safety guidelines issued by the Centers for Disease Control, OSHA, and other applicable health care authorities. If you feel uncomfortable in your work setting, you have the option of not coming to work. If you choose not to report for work, please notify your Insert Company Name Superintendent.
***** IF YOU ANSWER YES TO ANY OF THE 3 QUESTIONS IN THIS QUESTIONNAIRE, PLEASE CONTACT YOUR SUPERVISOR *****