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Home
Contact Us
About Us
FSC Certified
Order
Displays
Promotional
Labels
Services
Label Printing
Large Format Printing
High Speed UV Printing
HP Latex Board Printing
Digital Die Cutting
Building Wraps
LightJet Photographic Printing
Acrylic Facemount Prints
SEG Silicon Edge Graphics
Pro Photo Printing
Trade Show Displays
Offset Printing
Digital Printing
Direct Mail
Duplication
Blog
Portfolio
Application Gallery
Sony Installation
Quotes
Upload
Payment
Account
My Account
Orders
Downloads
Addresses
Home
Contact Us
About Us
FSC Certified
Order
Displays
Promotional
Labels
Services
Label Printing
Large Format Printing
High Speed UV Printing
HP Latex Board Printing
Digital Die Cutting
Building Wraps
LightJet Photographic Printing
Acrylic Facemount Prints
SEG Silicon Edge Graphics
Pro Photo Printing
Trade Show Displays
Offset Printing
Digital Printing
Direct Mail
Duplication
Blog
Portfolio
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Sony Installation
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Upload
Payment
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COVID-19 WELLNESS SELF ASSESSMENT AGREEMENT
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COVID-19 WELLNESS SELF ASSESSMENT AGREEMENT
COVID-19 WELLNESS SELF ASSESSMENT AGREEMENT
Paul Moebius
2021-02-24T12:00:59-08:00
COVID-19 WELLNESS SELF ASSESSMENT AGREEMENT
Digital Pro Inc. (DPI) is focused on the health and well-being of all personnel. As a result of the COVID-19 outbreak, we are taking precautionary measures to keep the workplace safe for everyone. Please help us maintain a safe environment by signing this Wellness Self-Assessment Agreement and agreeing to perform this wellness check each day prior to arriving on site. If you answer “yes” to any of these questions, do NOT report to any onsite work location. If you are an DPI employee, contact the Leave of Absence department at
[email protected]
to discuss next steps with your manager and to take time off to care for yourself or work from home.
Upon arrival, you may also be asked to submit to a noninvasive temperature check and/or be asked to confirm your self-assessment answers before entering our facilities. By completing this agreement, you certify you will perform this wellness self-assessment 2 hours prior to your arrival at any DPI facility and your response to each question is “no.” You also certify you will comply with all health and safety rules and procedures in effect at any applicable onsite work location.
Has your temperature been 100º F (38ºC) or more at any time during the 72-hour period before reporting to any onsite work location?
*
Yes
No
At any time during the 72-hour period before reporting to any onsite work location, have you experienced the following symptoms of COVID-19: cough, shortness of breath or difficulty breathing (unrelated to known medical conditions, e.g., asthma, allergies, etc.)?
*
Yes
No
At any time during the 72-hour period before reporting to any onsite work location, have you suffered from any two of the following: chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell?
*
Yes
No
Within the last 14 days, have you been in close contact (6 feet or less for more than 10 minutes) with anyone who has been diagnosed as COVID-19 positive by a healthcare provider, or is being screened or tested for COVID-19 due to symptoms or exposure (not for routine screening as part of their employment)?
*
Yes
No
Within the last 14 days, have you been in close contact (6 feet or less for more than 10 minutes) with anyone who has been advised to self-quarantine by a healthcare provider?
*
Yes
No
Have you recently tested positive for COVID-19 or been diagnosed as COVID-19 positive by a healthcare provider within the last 21 days? If “yes”, please contact the Leave of Absence department at
[email protected]
to assess a return to work strategy based on your medical diagnosis.
*
Yes
No
Legal Name
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Last
Email
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Office Location
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Poway West - 13257 Kirkham Way
Poway East - 13367 Kirkham Way
Poway North - 12300 Crosthwaite Circle
Las Vegas - 7260 Dean Martin Dr
Today's Date
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MM slash DD slash YYYY
Signature
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You must select the below box to receive a copy of the this form and DPI's Privacy Notice.
Agreement
*
This form is filled out truthfully and to the best of my knowledge.
Our collection, use and disclosure of the personal information in this form is governed by a Privacy Notice that describes how we are using that personal information (primarily, to manage the physical safety of our personnel in the workplace and ensure we comply with applicable public health orders and regulations) and explains your rights with regard to that information.
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