version 06-04-2020 Please click here to see AMG Pandemic Response Plan Health Screening Effective April 15th, 2020 AMG management is requiring all individuals residing in a home to complete this health screening prior to allowing one of our employees or associates in the home. All work required in the home will be on hold until the completed screening form is received by AMG. All personal health information will be held in strict confidence by AMG management. AMG management requires all individuals at the home be in a separate room and perform social distancing while our employees and associates are in the home. The following form can be filled out by one individual who is considered the head of the household on behalf of all occupants: Individual Name:*Lot # or Address:*Name of Builder, if any:*Name of Site, if any:*Date of Screening:* 1. Is anyone in the home currently experiencing any of the following COVID-19 related symptoms?* Severe chest pain (constant tightness or crushing sensation) Feeling confused or unsure of where you are Losing consciousness Fever (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher) Chills Cough that's new or worsening (continuous, more than usual) Barking cough, making a squeaky or whistling noise when breathing (croup) Shortness of breath (out of breath, unable to breathe deeply) Sore throat Difficulty swallowing Runny, stuffy or congested nose (not related to seasonal allergies) Lost sense of taste or smell Headache (unusual or long-lasting) Digestive issues (nausea / vomiting, diarrhea, stomach pain) Extreme Tiredness that is unusual (fatigue, lack of energy) Falling down more than usual Pink Eye YesNo2. Has anyone in the home experienced any of the above symptoms within the last 14 days?*YesNo3. Are you currently awaiting results of a COVID-19 test?*YesNo4. Were you asked to self-isolate by a healthcare professional, and have not yet completed the mandated 14-day isolation period, or have you recently returned from international travel?*YesNo5. Has anyone in the home recently returned from international travel, or were asked to self-isolate by a healthcare professional, and have not yet completed the mandated 14-day isolation period?*YesNo6. Has anyone in the home experienced any of the following exposures of concern?* *Close contact with a confirmed case *Close contact with someone who is being tested Living with someone who has returned from international travel or who has been asked to self-isolate Living with someone who has exhibited COVID-19 related symptoms (respiratory symptoms can include fever, cough or difficulty breathing) *Close contact means: a face-to-face conversation for 15 minutes or being in the same room for 2hrsYesNo Head of Household final confirmation:Manager Confirmation:* All occupants of the home have reviewed and agreed to comply with the Health and Safety policies (including social distancing and hygiene practices) during AMG site operations. If YES was answered to any of the above questions, the AMG employee or associate is not permitted access to the home.Additional Comments from head of household:CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.