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Effective Monday, January 31, 2022

COVID-19 Questionnaire for ALL visitors to UFCW Local 832 Office Spaces

Please review the following questions and choose YES or NO.

    Have you been informed or advised that you should self-isolate due to symptoms associated with COVID-19 or as a close contact of someone with COVID-19?

    Have you experienced any of the following symptoms in the last 14 days?

    More than two (2) combined symptoms will result in the denial of entry into the building for in-person meetings.

    Cough:

    Fever:

    Difficulty Breathing:

    Muscle Aches/Fatigue:

    Headache:

    Sore Throat:

    Runny Nose:

    Chest Congestion:

    Loss of taste or smell:

    Please enter your name:
    Please enter your workplace:
    Please enter your email:
    Please enter your phone number:

    Name of UFCW 832 staff you're meeting with:

    Todays Date:

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