Employee Covid19 Questionnaire - ECI Technology | We Keep Your Chemistry Right

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Employee Covid19 Questionnaire

Home / Employee Covid19 Questionnaire

Due to the Covid19 pandemic all ECI employees (and guests) are required to fill out the following questionnaire every day before entering the ECI facility.

Employee Disclosure
This information is necessary to assure the health and safety of our employees and facilities.
Name
Date
MM slash DD slash YYYY
Do you have a fever or above normal temperature? (100.4°F)*
- Yes
- No
Have you experienced shortness of breath or had trouble breathing?*
- Yes
- No
Do you have a dry cough?*
- Yes
- No
Have you recently lost or had a reduction in your sense of smell?*
- Yes
- No
Have you recently been in contact with someone who is symptomatic, pending test results or tested positive for COVID19?*
- Yes
- No
Have you tested positive for COVID-19?*
- Yes
- No
Have you been tested for COVID-19 and are awaiting results?*
- Yes
- No
Have you traveled internationally or to any US States listed on the NJ Travel Advisory in the past 14 days?*
- Yes
- No
By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Signature*
I understand that this information is necessary to assure the health and safety of our employees and facilities. By submitting this form I agree that the information will be used in accordance with company Human Resources policy and in full compliance with HIPAA regulations. It will not be shared with any third party or individual without my explicit consent.
Phone
This field is for validation purposes and should be left unchanged.

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