Mandatory COVID 19 Questionnaire

The attacehd form is a daily requirement for all Trades and Suppliers

attending any of Suburban's job sites and projects.

First and Last Name

Company

Phone #

Job/Project

Have you returned from outside of Canada (including Michigan) in the last 14 days?

Yes

Have you been in close contact with anyone who has traveled outside of Canada (including Michigan) in the last 14 days?

Yes

Are you currently or have you experienced in the last 14 days any of the following: Fever, cough, sore throat, difficulty breathing?

Yes

Are you currently waiting for the results of a COVID 19 test?

Yes

If you answered yes to any question, please elaborate

Today's Date

I declare that the info I’ve provided is accurate & complete

Your Signature