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2021 Employee Health Certification Form

  1. 1. Do you have any of the following symptoms? *
    If you answered YES to any of the symptoms listed above, return home and contact your healthcare provider. If NO, proceed to the remaining questions.
  2. Log your temperature below. If your temperature is above 100.4 Degrees F, return home and contact your healthcare provider. If your temperature is less than 100.4 Degrees F, proceed to the remaining questions.
  3. 3. Have you had close contact with an individual diagnosed with COVID-19? Close contact means within 6-feet or coming in direct contact with secretions (e.g., sharing utensils, being coughed or sneezed on, etc.). The timeframe for having contact with an individual includes the period of 48 hours before the individual became symptomatic.*
    If YES, return home and contact your healthcare provider. If NO, proceed to the remaining question.
  4. 4. Have you been asked to self-isolate or quarantine by your doctor or local public health official?*
    If YES, return home and contact your healthcare provider.
  5. By typing my name above, I certify that my responses are truthful and accurate to the best of my knowledge. I further understand that if I develop any of the above symptoms, I will be separated from other employees and participants and my Emergency Contact will be notified for immediate pick-up.
  6. Leave This Blank:

  7. This field is not part of the form submission.