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COVID Medical Exemption for Re-Deployment Form
This form is only to be used for a medical exemption if you are being re-deployed.
Employee ID *
Employee First Name *
Employee Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Email Address (hhsnj.org preferred) *
Phone Number *
Home Department *
Home Supervisor *
In your current role, do you provide direct patient care? *
Reassigned Department (if currently applicable)
Reassigned Supervisor (if currently applicable)
Have you recently traveled outside the county? *
Have you had contact with a known Coronavirus case? *
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