Dakkota Integrated Systems, LLC

Dakkota COVID-19 Employee/Visitor Questionnaire       updated as of 10/22/2020
Dakkota Integrated Systems, LLC
The safety of our employees, supplier partners, customers, families and visitors remain Dakkota’s overriding priority. As the coronavirus disease 2019 (COVID019) outbreak continues to evolve and spreads globally, Dakkota is monitoring the situation closely and will periodically update company guidance based on current recommendations from the Centers for Disease Control. Only business critical visitors are permitted at any Dakkota facility at this time. For a copy of Dakkota’s COVID-19 Playbook click here or see an HR representative to review a hard copy.

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire along with temperature screening. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you.
Dakkota Facility Name:  * Date:  *
Employee/Visitor Name:  * Personal Phone # (mobile/home):  *
Organization:  * Name of Dakkota Host:  *
Shift:  *
Self Declaration 
1 In the last 10 days, have you developed a new or unexplained cough, shortness of breath, or difficulty breathing?

Yes No
2 In the last 10 days, have you had two or more of these symptoms— fever (temperature of 100.4°F/38°C or higher), chills, new UNEXPLAINED headache, muscle/body aches, fatigue, sore throat, new loss of taste or smell, congestion/runny nose, nausea, vomiting, or diarrhea?

Yes No
3 Is your temperature today at 100.4°F/38°C or higher?

Yes No
4 Are you or a close contact currently awaiting COVID-19 test results due to COVID-19 symptoms or close contact exposure?  Close contact is someone you live with or whom you have been within 6 ft of for extended periods of time. Close contact does not include activities such as walking past someone or briefly sitting across a waiting room or office.

Yes No
5 Have you or a close contact been diagnosed with COVID-19 in the last 14 days?

Yes No Results Pending
6 Have you cared for someone diagnosed with COVID-19 within the last 14 days?

Yes No
Note: You are required to fill out this questionnaire daily.
Infor Global Solutions, Inc. Copyright © 2020 Dakkota Integrated Systems, LLC
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