MWI COVID-19 Screening Checklist
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By completing this form, I acknowledge that Mel Wheeler, Inc. is requesting this information in order to provide a healthy workplace for my co-workers and me. I understand this document and the information provided will be treated as a confidential medical record by the Company, and only disclosed or used as permitted by law.

I understand the Company is relying on my honesty, and I can be disciplined for making a false statement.
Name: *
Today's Date *
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In the past 24-hours, have you experienced: *
Required
If you answered ‘yes’ to any of the symptoms above, please do not come to the station. Please self-isolate at home, and contact your doctor for direction.
ADDITIONAL QUESTIONS
Have you had close contact in the last 14-days with an individual diagnosed with COVID-19, who is awaiting a COVID-19 test result, or who has exhibited symptoms of COVID-19? *
Have you engaged in any activity or travel within the last 14-days which fails to comply with the Virginia state guidelines? *
Have you been directed or told by the local health department or your healthcare provider to self-isolate or self-quarantine? *
If you answered "yes" to any of the additional questions above, please do not go into work. Self-quarantine at home for 14-days.
If you test positive for COVID-19 or are experiencing symptoms of COVID-19, you should follow all orders as directed by your healthcare provider. You must have a written notice from your healthcare provider before returning to work. If you have any questions about this questionnaire, please contact Cheryl.
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