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C1014A I <br /> Subcontractor Work Crew <br /> COVID-19 Daily Health Attestation <br /> Date: <br /> Company Name: <br /> Supervisor Name: Signature: <br /> Project Name: <br /> Site Address: <br /> Number of Workers on site: <br /> Prior to entry onto a field site, the following questions shall be asked by the Subcontractor Supervisor to their <br /> work crew. Subcontractors and Field Teams shall self-attest to vaccination status in order to ensure <br /> compliance with state/local guidance for fully vaccinated and unvaccinated individuals. <br /> It is preferred this questionnaire is completed for each individual prior to their arrival at the field site. If the answer <br /> to any of these questions is YES, the worker is not to report to the field site and seek proper medical advice, in <br /> accordance with CDC Guidelines. The Subcontractor Supervisor must provide this form on a daily basis <br /> to the Roux primary contact for the project and notify Roux of any YES responses. <br /> 1. Have you experienced any signs/symptoms of COVID-19 such as fever (>100.40F), cough, shortness of <br /> breath, chills, fatigue, muscle/body aches, headache, new loss of taste or smell, sore throat, congestion <br /> or runny nose, nausea/vomiting or diarrhea in the last 5 days? <br /> 2. Have you been in close contact* with someone who is suspected or confirmed to have COVID-19 or who <br /> is under investigation for COVID-19 within the last 5 days? <br /> *Close contact as defined by the CDC is being within 6 feet of someone who has COVID-19 for a cumulative <br /> total of 15 minutes or more over a 24-hour period. Those who are up to date on COVID-19 vaccinations or had <br /> confirmed COVID-19 within the past 90 days (you tested positive using a viral test) you do not need to <br /> quarantine. <br /> 3. Have you traveled outside of the country, been on a cruise ship and/or traveled to areas within the United <br /> States which have state mandated travel restrictions in the last 5 days? <br /> 4. Have you tested positive for COVID-19 within the last 5 days? <br /> Please list the crew member's names on site for the day. <br /> 1. 8. <br /> 2. 9. <br /> 3. 10. <br /> 4. 11. <br /> 5. 12. <br /> 6. 13. <br /> 7. 14. <br /> COVID-19 Daily Health Attestation ROUX 1 <br />