COVID 19 WAIVER

The safety of our employees, partners, customers, families and visitors remain our overriding priority.

This tool will help you assess your symptoms and determine if you're a good candidate for a COVID-19 test. It also offers guidance on when to seek medical care and what to do in the meantime. This information is based on Centers for Disease Control and Prevention (CDC) guidelines.

As we return to normalcy another (COVID-19) outbreak is mitigated by utilizing screening tools such as this one.

Based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions (e.g. serious heart disease, chronic lung disease or asthma, immunocompromised, severe liver disease, etc.) might be at higher risk for severe illness from COVID-19.

If you are concerned about underlying medical conditions, please consult with your personal medical health care provider.

Your participation is important to help us take precautionary measures to protect you and everyone in this facility. We request you complete this screening everyday prior to entering the facility.

Based on your response, you will be informed if you should report to work. Thank you for your time.

SCREENING QUESTIONS

IF YOU RESPOND YES, YOU ARE NOT REQUIRED TO PROVIDE ANY PERSONAL INFORMATION

1) In the last 14 days, have you received a confirmed diagnosis for coronavirus (COVID-19) by a coronavirus (COVID-19) test or from a diagnosis by a health care professional or are you waiting for a pending COVID-19 test result?

2) In the last 14 days, have you traveled internationally (except commuting between work and home by personal vehicle)?

3) In the last 14 days, have you had close contact with or cared for someone currently diagnosed with COVID-19 or are you participating in a COVID-19 clinical study that includes being exposed to the virus?

4) Have you experienced any cold or flu-like symptoms in the last 14 days including fever, cough, shortness of breath or difficulty breathing, sore throat, pressure in the chest, extreme fatigue, earache, persistent headache, diarrhea, vomiting, muscle pain, chills, repeated shaking with chills, and persistent loss of smell or taste?

Note: Answer “yes” if the symptoms you have experienced in the last 14 days are of greater intensity or frequency than what you normally experience.

Note: Answer “No” if you have been evaluated by a healthcare provider and have been released to return to work or you have had a negative COVID-19 test within 14 days after the onset of symptoms. You must provide either a return to work medical note from your healthcare provider and/or the results of the COVID-19 test to your facility medical department.

If you are able to answer “YES” to one or more of the above questions, select YES.

If you are able to answer “No” to all the questions, select NO.

Ford will use the information you provide for the purpose of providing you access to the facility and for management of business operations.

I HAVE ANSWERED NO TO ALL 4 QUESTIONS

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