Employee Return-to-Work Survey

Name
First Last
Health and Safety
Do you have any of these symptoms: fever, aches, cough, shortness of breath, chills, muscle pain, headache, sore throat, new loss of smell?*
- Yes
- No
Have you come in contact with anyone diagnosed with COVID-19?*
- Yes
- No
Are you currently waiting for the results of a COVID-19 test?*
- Yes
- No
Have you traveled outside Maryland over the last 14 days?*
- Yes
- No
Preparedness
Has your availability changed since you last worked with Baltimore Home Cleaning?*
- Yes
- No
Please explain why your availability has changed:*
What is your new work availability for Monday through Saturday?*
How do you feel about returning to work with Baltimore Home Cleaning?*
On a scale of 1-5, how concerned are you about the COVID-19 outbreak impacting your health or safety in the workplace?*
1 = Not at all concerned 2 3 4 5 = Extremely concerned
Acknowledgements*
- I understand my responsibility to not come to work if I have symptoms of COVID-19 or have recently come into contact with someone who has COVID-19.
- I understand my responsibility to comply with Baltimore Home Cleaning’s health and sanitation standards.

Health and Safety