Staff Health Form
Instructions:
- You will need to complete and submit one form each day when you begin your shift as described below.
- You must stay home from work and call your manager if, within the past 14 days: you have tested positive for COVID-19; you have knowingly been in close contact with anyone who has tested positive, or who has or had symptoms of COVID-19; or if you have experienced any symptoms of COVID-19 including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, sore throat, and new loss of taste or smell.
- Carefully review the information below, complete the attestation every day, and submit the completed form to your manager (or electronically as directed) when you report to work and begin your shift each day.
I certify that I:
- Have not knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19;
- Have not tested positive for COVID-19 in the past 14 days; and
- Am not experiencing and have not experienced any symptoms of COVID-19 in the past 14 days, including cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, sore throat, and new loss of taste or smell.
Note: If you do not meet the above criteria, you must stay home and notify your manager.
By signing my name, I certify that I meet the above criteria and that the attestation is true.
