Self-Declaration Screening Questionnaire Form
The safety of our employees, customers, families and visitors remains HM White’s overriding priority. HMWhite Coronavirus Response Plan Policy documents are located here.
To prevent the spread of COVID-19 and reduce the potential risk of exposure to our customers, employees and visitors, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.
| Visitor/Employee Name | |
| Company/Organization | |
| Email Address | |
| Personal Phone Number | |
| HMWhite Office/Project Location |
Self-Declaration by Employee/Visitor
| Have you traveled by airplane internationally within the last 14 days? | YesNo |
| Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? | YesNo |
| Have you received a confirmed diagnosis of coronavirus by a coronavirus test or from a diagnosis by a health care professional within the last 14 days? | YesNo |
| Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)? | YesNo |
If the answer is “yes” to any of the questions, access to the facility is denied.
Any questions should be directed to
- Karmen Wagner, (313) 531-8477, FHull@HMWhite.com
- Pete Garcia, (313) 531-8477, PGarcia@HMWhite.com
