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COVID-19 Attestation Form
If you answer yes to questions 5, 6, or 7 please notify Human Resources and your supervisor and leave the office immediately.
Name *
2. Date *
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3. What locations (office, client home, court, county office, etc,) are you working in today? *
4. Did you take your temperature today? *
5. Do you have a fever of 100.4 or more? (If you answer yes to this question you must leave the office immediately and notify Human Resources and your supervisor.) *
6. Do you have any of the following symptoms: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, or Diarrhea? (If you answer yes to this question you must leave the office immediately and notify Human Resources and your supervisor.) *
7 Have you tested positive in the last 10 days or been exposed to someone who has tested positive to COVID-19 in the last 14 days? (If yes to this question you must leave the office immediately and notify your supervisor and Human Resources) *
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