VPI Employee & Visitor Health Declaration – Announcement 3/20/20

VPI Visitors and VPI Employees Returning from an Absence:

The safety of our employees, customers, families, and visitors remains Valley Packaging Industries’ (VPI’s) main priority. In an effort to protect against the COVID-19 virus, we have implemented certain protocols. As an interim measure, we are asking all visitors, customers and employees that have been absent from work, to complete this health declaration prior to entering any of our facilities. This form is voluntary; however, you will not be allowed access to any VPI facility or workplace if you decline to fully respond. The data we collect will be used solely for purposes of preventing COVID-19 transmission and/or responding to a future COVID-19 diagnosis and will not be shared with anyone beyond those who reasonably need to know in order to apply VPI workplace safety policies, or as required by a public health authority or other such body.

Health Questionnaire

In the past 14 days, have you been in close contact with anyone who has been diagnosed with or reasonably suspected of having COVID-19? Yes No
Have you been advised by a doctor, healthcare provider, or any public health authority to stay home or otherwise avoid contact with others? Yes No
Do you now or have you recently had a fever, cough, shortness of breath, or other respiratory symptoms? Yes No
In the past 14 days, have you traveled to or connected through a location under CDC Level 3 travel advisory (please note that the level 3 travel may change rapidly but is currently China, South Korea, Iran and all countries in Europe)? *Refer to www.cdc.gov for up to date information on level 3 travel advisories. Yes No

Note: If you have answered “Yes” to any of the questions above, you will not be allowed on the site.

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Printed Name                                              Signature                                                     Date