Employee Health Reporting Agreement
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Employee Health Reporting Agreement
People with COVID-19 have had a wide range of symptoms reported – ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus.
Employees should self-monitor daily for these COVID-19 symptoms:
1. Cough
2. Shortness of breath or difficulty breathing
3. Fever >=100.4F
4. Chills
5. Muscle pain
6. Sore throat
7. New loss of taste or smell This list is not all inclusive. Other less common symptoms have been reported, including gastrointestinal symptoms like nausea, vomiting, or diarrhea.
Employees must report if they are diagnosed with COVID-19:  by a positive lab test, or  diagnosis from a health care provider (without lab testing)
Employees must also report COVID-19 Exposures:  Living with a person that has been diagnosed with COVID-19, or  Having close contact with a person that has been diagnosed with COVID-19
I understand the Employee Health Reporting Agreement for COVID-19 and agree to:  
1. Self-monitor prior to reporting to work each day.
2. Report symptoms, positive diagnosis or exposure to COVID-19 to the Person-in-Charge.  
3. Follow the exclusions and/or restrictions that may be required of me.  
I understand and agree to follow all best practices adopted by my business to prevent the spread of COVID-19 including but not limited to:  1. Communicate virtually whenever possible. 2. Limit in-person meetings and gatherings.  3. Practice frequent hand hygiene. 4. Wear PPE (cloth face coverings, masks, gloves, eye protection, etc) required by my employer. 5. Maintain social distancing with other employees, customers, and clients. 6. Follow heightened cleaning and sanitizing of workspace and equipment.

By typing my name below I acknowledge that I have read, understand and will abide by my responsibilities as outlined in the Employee Health Reporting  Agreement  above.   Type your full name below. *
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