Self-Identification Survey Please enable JavaScript in your browser to complete this form.Name *FirstLastPositionBranch LocationExposure to COVID-191. Have you been exposed to COVID-19? YesNo2. Do you live with anyone who has been exposed to COVID-19 in the last 14 days?YesNoHigh Risk Individuals3. Individuals who fall within one of these high-risk categories may be entitled to a temporary accommodation. If you fit into one of these categories and you would like to be considered for an accommodation, please check “Yes.” Human Resources will follow up with you individually.YesNoAccording to the CDC, those at high risk of severe illness from COVID-19 are: People aged 65 and older People of all ages with underlying medical conditions, particularly if not well controlled, including: People with chronic lung disease or moderate to severe asthma – People with a serious heart condition – People who are immunocompromised, which includes many conditions and factors such as cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of Corticosteroids and other immune-weakening medications People with severe obesity (BMI of 40 or higher) People with diabetes People with chronic kidney disease who are undergoing dialysis People with liver disease 4. Do you live with or regularly care for anyone who is high risk? YesNoIndividuals with Childcare ConcernsCornerstone expects to follow applicable federal, state, and local guidelines on getting back to work. At this time, specific guidelines for opening childcare facilities remain uncertain. With that said, please answer the below questions to the best of your ability.5. At this time, are you responsible or sharing responsibility for childcare in your home?YesNoIf you answered "yes" to the question above, will your childcare responsibilities allow you to work onsite during the following time periods: Monday-Friday, 8am -5pm OR your normally-scheduled working hours.YesNoTravel6. Have you or any immediate family members traveled outside of the United States in the last 14 days or been in close contact with anyone who has?YesNo7. Do you use mass transit such as a bus or train to travel to work?YesNoAdditional Limitations8. Are there any other limitations that would affect your immediate return to the worksite?YesNoIf "yes" please explain in the box belowEmailSubmit
