COVID-19 Check List Date* MM DD YYYY Name* First Last Company*Great Lakes Aggregates, LLC Location Visiting*Sylvania Minerals QuarryRecycled Aggregates, LLC TaylorRecycled Aggregates, LLC Rochester Hills/CrooksRecycled Aggregates, LLC Salem/Chubb RoadRecycled Aggregates, LLC New HavenRecycled Aggregates, LLC Highland ParkAre 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?*YesNo Within the last 14 days:Have you, or anyone in your family, been in contact with a person that tested positive for COVID-19?*YesNoHave you, or anyone in your family, been in contact with a person that is in the process of being tested for COVID-19?*YesNoHave you or anyone you live with traveled internationally or domestically?*YesNoHave you been medically directed to self-quarantine due to possible exposure to COVID-19?*YesNoIf 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.NameThis field is for validation purposes and should be left unchanged.