At Door Daily Wellness Questionnaire First Name Last Name Office LocationPlease select... Columbia Louisville Macon Murfreesboro San Diego Other DepartmentPlease select... Accounting Audit Claims IT Loss Control Marketing Support Underwriting Other Do you currently have a temperature of 100.4 F (99.4 F by forehead) or greaterYesNo Current temperature Name of Person Taking Temperature Please take the following action and submit this formI have instructed the employee not to enter the office and to contact his/her supervisor for guidance. In the last 14 days, have you had a fever?YesNo Contact your supervisor for guidanceI have made contact with my supervisor and discussed the situation.I was unable to reach my supervisor and have left a message with him/her. In the last 14 days, have you presented any symptoms of COVID-19?YesNo Contact your supervisor for guidanceI have made contact with my supervisor and discussed the situation.I was unable to reach my supervisor and have left a message with him/her. In the last 14 days, have you tested positive for COVID-19?YesNo Do not enter the office. Please contact your supervisor immediately for discussion. I have made contact with my supervisor and discussed the situation.I was unable to reach my supervisor and have left a message with him/her. In the last 14 days, have you been exposed to anyone who has tested positive to COVID-19?YesNo Do not enter the office. Please contact your supervisor immediately for discussion. I have made contact with my supervisor and discussed the situation.I was unable to reach my supervisor and have left a message with him/her. In the last 14 days, have you traveled out of state?YesNo Contact your supervisor for guidanceI have made contact with my supervisor and discussed the situation.I was unable to reach my supervisor and have left a message with him/her. Are you unable to wear personal protective equipment due to a health reason?YesNo Contact your supervisor for guidanceI have made contact with my supervisor and have discussed the situation.I was unable to reach my supervisor and have left a message with him/her. Do you have a mask to wear while working in the office (whether personal or MIA provided)?YesNo Masks are available for your use in the office. Contact your supervisor or any member of managementI have obtained a mask I acknowledge that I am required by MIA to clean/sanitize my own desk and personal work space. In the absence of separate disinfectant solution/wipes, hand sanitizer may be used to clean/sanitize desks and other work surfaces. Hand sanitizer stations are located inside the entry way of the office. Please contact your supervisor for additional resources available in your location.I acknowledge the above I acknowledge that common areas of MIA offices are closed for use (examples: reception area; breakrooms except to store/retrieve food from refrigerators and use of vending machines)I acknowledge the above I am working in the office todayYesNo
