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Do you have any COVID-19 symptoms?(Required)
Fever above 100.4° | Cough | Shortness of Breath | Difficulty Breathing | Chills | Repeated shaking with chills | Headache | Sore Throat | New loss of taste or smell | Diarrhea | Vomiting | Muscle Pain (not related to work or home activity)
Have you taken any medication for the purpose of reducing a fever with the last 24 hours?(Required)
Have you worked in another facility that has confirmed COVID-19 cases in the last 14 days?(Required)
Have you been in close contact with anyone diagnosed with COVID-19 in the last 14 days?(Required)
Have you been in close contact with anyone with COVID-19 symptoms in the last 48 hours?(Required)
Have you been in close contact with anyone with COVID-19 symptoms in the last 48 hours?(Required)
If YES to any, the employee is not permitted to enter the facility and must go home and notify their supervisor.
If proceeding onsite, the individual must remember to:
• Wash or sanitize their hands using an alcohol-based hand sanitizer at least every 60 minutes
• Not shake hands with or touch individuals
• Stay in their assigned work area as much as possible
• Use only the designated bathroom for their department
• Wear their mask at all times, except during lunch breaks
• Maintain social distancing, at least 6 feet, as much as possible.
I have read the requirements to enter the building and attest that by signing this form I am in compliance with noted requirements.