COVID-19 (CORONAVIRUS) QUESTIONNAIRE

As part of its dedication to maintaining a safe and healthy work environment, Staffing Synergies, Inc. (Staffing) requires all employees or visitors to any facility where Staffing provides services to answer the following questions prior to entry into such facility regarding the SARS-CoV-2 virus and COVID-19 disease (together “coronavirus”):

1.

Have you traveled to areas identified as high risk of coronavirus in the last 30 days, includingbut not limited to China, Italy, South Korea, Japan or Iran?

No

2.

Have you had contact with someone diagnosed with coronavirus or someone showing itssymptoms (specifically, fever, coughing or shortness of breath)?

No

3.

Have you had contact with any healthcare workers or other individuals caring for patients with coronavirus?

No

4.

Have you experienced any flu like symptoms, specifically fever, coughing or shortness of breath,in the past week?

No

If you answered “yes” to any of the questions above, please do not enter this facility and instead seek further guidance as set forth on the CDC website located at:

If any answer to the above questions changes after completing this survey, then you are responsible to report those changes to Staffing Synergies HR reps immediately.

The undersigned agrees to follow all social distancing guidelines and any other protective measures as directed by management. Failure to do so may result in termination of employment.

Name:

luke5983

Date: