Pre-Service Questionnaire

Contact Name

Contact Email

Contact Phone

Company Name

Facility Name

Street Address

City

State

Zip Code

A. Regulatory Compliance

Company is an Essential Business that is allowed to operate under current federal, state, and local regulations

Yes
No

B. COVID-19 Incidents

Number of Company staff currently diagnosed with COVID-19 or suspected of being infected

Total number of Company staff that have been diagnosed with COVID-19

Date of last diagnosed case of COVID-19 among Company staff (mm/dd/yyyy)

Company has documented infection handling procedures

Yes
No

C. Infection Prevention Measures

Company screens workers daily for viral infection symptoms

Yes
No

Workforce maintains 6' of separation while on job

Yes
No

Staff are required to wear face masks when within 6' of coworkers

Yes
No

D. Testing Conditions

Company will exclude from testing workers with a persistent cough or sneeze

Yes
No

Company will exclude from testing workers with COVID-19 symptoms, including fever, cough, shortness of breath, sore throat, headache and chills

Yes
No

Company will have workers wash hands or use sanitizer immediately prior to testing

Yes
No

Company will supply workers with a CDC-approved face mask during testing

Yes
No

Company will require test subjects to social distance from other workers and T K Group staff where possible during the testing process

Yes
No

E. Infection Notification

Company will promptly notify T K Group of new infections among its workforce prior to the arrival of T K Group on site

Yes
No

Company will promptly notify T K Group if worker subsequently found to have been infected while we were on site

Yes
No

Company wishes to be notified by T K Group if a technician was subsequently found to have been infected while on site

Yes
No

Notification Contact Name

Notification Contact Email

Notification Contact Phone

T K Group Notification Contact

Name: Denise Wingo

Title: Director of Operations

Phone: 815.332.3460

Email: denisewingo@tkgrouphearing.com