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Pre-Shift Health Safeguard Form
Please fill the COVID-19 form
Employee should fill the following details before commencing the work on a daily basis.
Full Name:
First Name
Last Name
This field is required.Please enter value
This field is required.Please enter value
Mobile No:
This field is required.Please enter value
Invalid phone number.
The value must be less than or equal to 20
Email id:
This field is required.Please enter value
Please enter valid email address
Position:
Driver
Dispatcher or Admin - In Office
Dispatcher or Admin - Work from Home
This field is required.Please enter value
Any fever above 100.4° F in the past 72 hours or any fever symptoms:
Yes
No
This field is required.Please enter value
Have you come across following symptoms in the past one week consistently that you cannot attribute to another health condition: cough, shortness of breath or difficulty breathing, sore throat, loss of taste/smell, muscle aches, headache:
Yes
No
This field is required.Please enter value
Has any member of your household isolated with a suspected or diagnosed COVID-19 case, or been sick with symptoms consistent with COVID-19 In the last 14 days:
Yes
No
This field is required.Please enter value
Have you had close contact (within 6 feet for more than 10 minutes) with any suspect COVID-19 symptoms:
Yes
No
This field is required.Please enter value
Comments:
This field is required.Please enter value
Submit