Shults Auto Group
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Covid-19 Questionnaire
Dealership
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Ed Shults Chevrolet Cadillac
Shults Nissan Subaru
Ed Shults Ford Lincoln
Kia of Jamestown
Shults Hyundai
Ed Shults of Warren
Shults Resale Center Olean
Shults Resale Center Dunkirk
Auto Credit of Jamestown
Shults Toyota
Edmond 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:
Cancel
Save