COVID-19 COVID-19 Information Hill Machinery Covid-19 Form (For Printing) Hill Machinery CompanyHiddenCovid-19 The safety of our employees, supplier partners, customers, families and visitors remain our overriding priority. As the coronavirus (COVID-19) outbreak continues to evolve and spreads globally, we are continuing to monitor the situation closely and will periodically update our company guidelines based on recommendations from the CDC and WHO. To date, only business critical visitors are permitted at our Grand Rapids’ facility at this time. 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. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.Visitor's Name:* First Last Visitor's Phone Number:*Visitor's Company / Organization:* Name Of Hill Machinery Host: Visitor Self-DeclarationHave you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)?* Yes No Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days?* Yes No Has your immediate family or others you have frequent contact with returned from any COVID-19 affected area in the last 14 days?* Yes No Have you returned from any COVID-19 affected areas in the last 14 days?* Yes No SignatureSignature*Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920If you plan to be onsite for consecutive days, please immediately advise your host if any of your responses change. The information collected will to determine your access rights to Hill Machinery Company facilities. You will be contacted if any person at the facility contracts the virus.* I Agree I Do Not Agree PhoneThis field is for validation purposes and should be left unchanged.