COVID19 Employee Self Certification Return to Work Form

Form Reference Number 7

Temperature

First Name *

Last Name *

Employee ID

Phone Number

Email

Have you had fever within the last 7 days?

Did you experience any chills during the last 7 days?

Do you have a cough or have you had any throat irritation within the last 7 days?

Do you experience any difficulty in breathing or experiencing any shortness of breath (at rest or laying down)

Have you had any sore throat during the last 7 days?

Are you experiencing any sense of fatigue?

Do you have any gastrointestinal symptoms such as nausea, vomiting, diarrhea, loss of appetite?

Are you recently experiencing headache?

Are you experiencing muscle or joint pains?

Do you have a runny nose or experiencing nasal congestion?

Are you experiencing any unexplained loss of sense of smell or taste?

Have you been exposed to any person suspected or confirmed case of COVID-19 within the last 7 days?

Have you visited another country or state within the last 7 days?

Reminders *

If you have a fever or your body temperature measures above 100.3 (37.9 C) degrees or greater, having chills and shortness of breath, cough, or sore throat, it is best to rest or see the nearest hospital.
Avoid touching your eyes, nose, mouth, or being in close contact with people who are sick
Cover your mouth and nose when coughing or sneezing.
Regularly disinfect your hands whenever touching objects.
Wash your hands often with soap and water for at least 20 seconds.