Covid-19 Questionnaire

Dealership Select Dealership Ed Shults Chevrolet CadillacShults Nissan SubaruEd Shults Ford LincolnKia of JamestownShults HyundaiEd Shults of WarrenShults Resale Center OleanShults Resale Center DunkirkAuto Credit of JamestownShults ToyotaEdmond Chevrolet

Employee ID Number/Vendor Name

Name

In the past 14 days, have you experienced:

Fever (Temperature over 100.4 degrees) Yes No

Cough Yes No

Fatigue Yes No

Sneezing Yes No

Aches and Pains Yes No

Runny or Stuffy Nose Yes No

Sore Throat Yes No

Diarrhea Yes No

Headaches Yes No

Shortness of Breath Yes No

Have you recently been in close contact with anyone who has exhibited any symptoms? Yes No

Have you had a positive COVID-19 test in the past 14 days? Yes No

Have you recently been in contact with a confirmed or suspected COVID-19 case in the past 14 days? Yes No

Have you recently traveled outside of the following counties: Mckean, Warren, Cattaraugus, or Chautauqua? Yes No

Temperature (Fail if temperature over 100.4 degrees) Fail Pass

If yes, please explain where and when: