COVID-19 Workplace Health Screening

Allegan County Preparedness, Response and Safe Workplace Plan

http://www.allegancounty.org/safeworkplan

Employees and Contractors entering Allegan County facilities are required to complete this form each day you will be onsite, prior to your arrival. All occupants of the building are required to wear a face mask, if medically able, when entering an Allegan County facility. Thank you in advance for your cooperation and understanding.

Contractors shall conduct screening prior to proceeding to the worksite/County facilities and shall coordinate with the service area hosting the visit to discuss the impact of travel plans.

If you receive a probable diagnosis or test positive for COVID-19 call your local health department to ensure they are aware.

1. Company Name (if other than Allegan County):

2. Your Name (First and Last): *This question is required.

3. Service Area(s): *This question is required.

4. Supervisor or Host email address: *This question is required. (for contractors, enter organizational contact) This question requires a valid email address.

5. Your email address (if you would like a copy): This question requires a valid email address.