COVID-19 Check List Date* Month Day Year Name* First Last Company* Great Lakes Aggregates, LLC Location Visiting* Sylvania Minerals Quarry Recycled Aggregates, LLC Taylor Recycled Aggregates, LLC Rochester Hills/Crooks Recycled Aggregates, LLC Salem/Chubb Road Recycled Aggregates, LLC New Haven Recycled Aggregates, LLC Highland Park Are you having trouble breathing or have you had flu-like symptoms within the past 48 hours, including: fever, cough, shortness of breath, sore throat, runny/stuffy nose, body aches, chills, fatigue or loss of smell/taste?* Yes No Within the last 14 days:Have you, or anyone in your family, been in contact with a person that tested positive for COVID-19?* Yes No Have you, or anyone in your family, been in contact with a person that is in the process of being tested for COVID-19?* Yes No Have you or anyone you live with traveled internationally or domestically?* Yes No Have you been medically directed to self-quarantine due to possible exposure to COVID-19?* Yes No If you have answered yes to ANY of the five questions above, please leave the Great Lakes Aggregates, LLC location and notify your Supervisor of our request. Your submission of this form is our notification.PhoneThis field is for validation purposes and should be left unchanged.