Orchard Lake Country Club Employee Tracking Form

COVID-19 Tracking Form

for Orchard Lake Country Club Employees.
At OLCC, we want to create a healthy and safe working environment. We appreciate you taking the time to fill out this COVID-19 tracking form. Please let me know if you have any questions.

Sincerely,
Peter Swick
OLCC Manager
Do you consent to release this information to Orchard Lake Country Club? *

Yes No
Name: *

First Name Last Name
In which department do you work in at OLCC? *
Screening questions
Are you experiencing cough? *

Yes No
Are you experiencing fever? *

Yes No
Are you experiencing shortness of breath? *

Yes No
Are you experiencing sore throat? *

Yes No
Are you experiencing runny/stuffy nose? *

Yes No
Are you experiencing abdominal pain? *

Yes No
Are you experiencing nausea or vomitting? *

Yes No
Are you experiencing diarrhea? *

Yes No
Are you experiencing muscle aches/fatigue? *

Yes No
Are you experiencing loss of smell or taste? *

Yes No
Have you traveled outside of Michigan within the last 14 days? *

Yes No
Please list all countries/states: *
Have you had close contact with anyone diagnosed with the COVID-19 illness within the last 14 days? *

Yes No
Temperature: *
Should be Empty:

COVID-19 Tracking Form