GBFB Covid-19 Health Screening Questionnaire

This questionnaire applies to GBFB employees, consultants, contractors, vendors, clients and all other third-party visitors onsite at the GBFB office, and is part of GBFB's COVID-19 Reentry Protocol. Prior to entering GBFB office each day, you are required to fill out this questionnaire.

Completion of this form will automatically be sent to GBFB Human Resources staff.

Refusal to fill out this questionnaire may result in barring your entry to GBFB's premises or disciplinary action.

Please complete and check the corresponding box if you are currently experiencing or have experienced any of the following in the past 24 hours.

You are Only authorized to enter 70 South Bay Avenue or work at an Off-site location if you answered NO to Questions 1-3 OR answered NO to Question 1-2 AND YES to Questions 3 AND 3.1.

By entering your name or email address you agree that the submitted information is accurate.

All information obtained will be kept confidential, subject to applicable law. GBFB reserves the right to modify the above symptom list in accordance with official public health guidance.

(v20211206)

You are ONLY authorized to enter 70 South Bay Avenue if you answered NO to Questions 1-3 OR answered NO to Question 1-2 AND YES to Questions 3 AND 3.1.

By entering your name or email address you agree that the submitted information is accurate.

All information obtained will be kept confidential, subject to applicable law. GBFB reserves the right to modify the above symptom list in accordance with official public health guidance.

(v20211206)