Health Self-Certification Form — COVID-19

All employees must complete a Health Self-Certification Form questionnaire each day either online or using a paper form for Level 1 or above. Please answer the following questions prior to coming to work:

First Name

Last Name

If you desire a copy of this signed document, replace the below with your own email address

Site
---ABCEABCIABCLABCPHTILMPIIMPILSPIBSPIJSPILSPIPSPIR

1) Have you experienced any of the following common symptoms in the past 24 hours?
*Fever (above 100 degrees F in US or 37.5 degrees C in Mexico) or chills
*Cough (not typical or caused by existing condition)
*Shortness of breath/difficulty breathing (not typical or caused by existing condition)
*Fatigue (not typical, related to physical activity or caused by existing condition)*
*Muscle or body aches (not typical, related to physical activity or caused by existing condition)
*Headache (not typical or caused by existing condition)
*New loss of taste or smell
*Sore throat
*Congestion or runny nose
*Nausea or vomiting
*Diarrhea
YesNo

2) Have you tested positive for COVID-19 and not yet been cleared by a medical professional to return to work?
YesNo

3) Have you knowingly been in close contact (i.e. within 6 feet for more than 10 minutes) with someone diagnosed with COVID-19 in the past 14 days?
YesNo

4) Are you fully vaccinated for COVID-19?
YesNo

If you answered "Yes" to 1 or 2 above or answered "Yes" to 3 above and are not fully vaccinated, do not show up for work and report your absence to the call-in attendance line. Otherwise, please come to work and please remember to push 'Submit' below and then PROVIDE YOUR SIGNATURE on the page that opens up. The process concludes only after providing your signature and then pushing the Agree & Sign button