Health Self-Certification Form -- COVID-19


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 answer is “Yes” to questions 1 or 2 below or answer is “Yes” to question 3 and employee is not fully vaccinated, employee should not show up for work but instead should report his or her absence to the call-in attendance line

Follows are the responses submitted electronically by   on 

  1. Have you experienced any of the following 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

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

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

  4.  Are you full vaccinated for COVID-19?

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.

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Signature Certificate
Document name: Health Self-Certification Form -- COVID-19
lock iconUnique Document ID: 9f00342ae83cc2b88e0a42ce926810f01b045455
Timestamp Audit
January 31, 2021 9:55 am EDTHealth Self-Certification Form -- COVID-19 Uploaded by MPI Webadmin - [email protected] IP 50.90.201.143
January 31, 2021 10:56 am EDTCOVID FORM - [email protected] added by MPI Webadmin - [email protected] as a CC'd Recipient Ip: 50.90.201.143
August 22, 2021 3:22 pm EDTCOVID FORM - [email protected] added by MPI Webadmin - [email protected] as a CC'd Recipient Ip: 50.90.201.143