Dakkota Integrated Systems, LLC

Dakkota COVID-19 Employee/Visitor Questionnaire       updated as of 11/23/2020
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 Have you been diagnosed with COVID-19 in the last 10 days?

Yes No Results Pending
5 Have you recovered from COVID-19 in the past 90 days?

Yes No
6 Are you currently awaiting COVID-19 test results due to COVID-19 symptoms or close contact exposure?  Close contact is defined as someone you live with or whom you have been within 6 ft for 15 minutes or longer. Close contact does not include activities such as walking past someone or briefly sitting across a waiting room or office.

Yes No
7 Have you been in close contact with someone that has been diagnosed with COVID-19 within the last 14 days?

Yes No
8 In the past 14 days, is someone in your household quarantining due to close contact exposure with someone diagnosed with COVID-19 AND experiencing COVID-19 symptoms?

Yes No
9 In the last 14 days have you travelled internationally (except for purpose of commuting to work)?
Yes No
Note: You are required to fill out this questionnaire daily.
 
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