COVID

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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 going to be “yes” to any of the following questions, do not report for work and instead follow your normal absence call-in procedures; there is no need to fill this form out if you are going to mark “yes” for any of the 4 questions.


Employee Company



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


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


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?



You will be asked to provide your signature once you hit the 'send' button below - please complete the signature process on the next page.