810-327-6251

COVID-19 Check

Date*
Date Format: MM slash DD slash YYYY
Name*
First Last
Company*
Mid Michigan Materials Location Visiting*
- Betchel
- Burgess
- Vella
- Wilson
Are you having trouble breathing or have you had flu-like symptoms within the past 48 hours, including: fever, cough, shortness of breath, sore throat, runny/stuffy nose, body aches, chills, fatigue or loss of smell/taste?*
- Yes
- No
Within the last 14 days:
Have you, or anyone in your family, been in contact with a person that tested positive for COVID-19?*
- Yes
- No
Have you, or anyone in your family, been in contact with a person that is in the process of being tested for COVID-19?*
- Yes
- No
Have you or anyone you live with traveled internationally or domestically?*
- Yes
- No
Have you been medically directed to self-quarantine due to possible exposure to COVID-19?*
- Yes
- No
If you have answered yes to ANY of the five questions above, please leave the Mid Michigan Materials location and notify your Supervisor of our request. Your submission of this form is our notification.
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