COVID-19 Questionnaire


Health Self-Certification Form — COVID-19

 

All employees must complete and turn in a Health Self-Certification Form questionnaire daily either online or using a paper form.  All forms will be reviewed by Human Resources and remain confidential in the Human Resources offices.  These measures are necessary to reduce the risk of exposure and spread of COVID-19.

If the answer is “yes” to any of the following questions, do not show up for work and instead follow your normal absence call-in procedures.

Follows are the responses submitted electronically by   on 

  1. Have you experienced either one of the following symptoms in the past 24 hours? 

Selected symptom(s):

   2.  Have you experienced any two of the following symptoms in the past 24 hours?  

Selected symptom(s):

  3.  Have you tested positive for COVID-19 or been asked by a medical professional to be tested for COVID-19 in the past 14 days?   

  4.  Have you knowingly been in close contact with someone who has been infected with COVID-19 or asked by a medical professional to be tested for COVID-19 in the past 14 days?   

I attest that I have willingly and truthfully answered all questions above.  I will notify my supervisor immediately if any of my answers above change during my shift/workday.  I will comply with the recommendations and policies contained in the Employee Prevention Responsibilities document.

 

 

Leave this empty:

Signature Certificate
Document name: COVID-19 Questionnaire
Unique Document ID: aca62d304662afa554e7c09eb6d69bd9e15da767
Timestamp Audit
April 29, 2020 2:43 pm EDTCOVID-19 Questionnaire Uploaded by MPI Webadmin - [email protected] IP 50.90.201.143
April 30, 2020 2:22 pm EDTHR Team - [email protected] added by MPI Webadmin - [email protected] as a CC'd Recipient Ip: 4.53.198.150