Condo/Commercial Customer Health Screening Form - Pipelining Technologies, Inc.

Condo/Commercial Health Screening Form

Name

Company/Condo Name

Phone

Worksite Address

City

State

Zip Code

Have you or anyone in your building/community/business been diagnosed with or presumed to have Covid-19 or Coronavirus?

Yes No

Have you or anyone in your building/community/business had symptoms such as fever, cough, or respiratory issues in the last two weeks?

Yes No

Do you or anyone in your building/community/business believe they might have been in contact with someone who has shown symptoms of or has been diagnosed with Covid-19 within the last two weeks?

Yes No

By checking "Yes," I agree to keep in daily contact with my Pipelining Technologies, Inc. representative and inform them IMMEDIATELY of ANY changes. By checking "No," I understand that service will be suspended until a Health Screening is deemed acceptable and a safe working environment can be provided to Pipelining Technologies team members.

Yes No

Condo/Commercial Health Screening Form

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