Infectious Disease Control Plan - COVID-19 - Flipbook - Page 45
Consent to Company Wellness Screening
Employee/Vendor Name:
___________________________________________________________________
I hereby agree and consent to having Teamwrkx Construction, Inc. (“Company”) administer each of the
following wellness screenings prior to entry onto the ___________________ project (“Project”):
(1) have my temperature read by a Digital Infrared Thermometer; and
(2) be assessed for any signs of respiratory symptoms.
I further understand that:
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The Company’s screening protocol is administered in compliance with Santa Clara County’s
mandated Project Safety Protocol orders and CDC guidelines.
The results of each screening will be documented by Company and will be maintained securely
and confidentially by Company.
Completing these screenings are a requirement to be allowed entry onto the Project.
The screening results will not be used by Company for the purposes of individual health
information or to make a diagnosis of any disease or illness.
I am responsible for contacting my primary care physician or other physician for questions
about any specific medical needs that may be indicated by these screenings. I will not hold
Company responsible for providing screening or COVID-19 information, and such screening and
information is not a substitute for diagnosis, treatment or care by a physician or other qualified
healthcare provider.
If my temperature is over 100.4 F degrees and/or I exhibit any respiratory symptoms, I will be
sent home and will not be allowed to enter the Project and will not be permitted entry onto the
Project.
I recognize that if I do not sign this Consent, Company cannot administer the screenings, and I will not
have completed the first step to be eligible for entry on to the Project and will not be permitted entry
onto the Project.
I have read, understand and agree to the contents of this consent form.
___________________________________
Signature
________________________________
Date
___________________________________
Name (Print)
45
