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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 *
Your answer
Employee First Name *
Your answer
Employee Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Email Address (hhsnj.org preferred) *
Your answer
Phone Number *
Your answer
Home Department *
Your answer
Home Supervisor *
Your answer
Reassigned Department (if currently applicable)
Your answer
Reassigned Supervisor (if currently applicable)
Your answer
Have you recently traveled outside the county? *
Have you had contact with a known Coronavirus case? *
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