Daily COVID-19 Self Certification

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Mass Coastal Railroad

First Name *

Last Name *

Phone Number *

What Department do you work in? *

Are you experiencing any signs or symptoms to include Fever, Soar Throat, Body Aches or Loss of Taste/Smell? *

Yes

Have you had a "close contact" with an individual diagnosed with COVID-19? *Close contact is described as living in same household who has tested positive, been within 6' of a +COVID-19 person more than 15 minutes or in contact with secretions from a +COVID-19 symptomatic person. *

Yes

Have you been in contact with anyone who is awaiting a test result or someone that has been tested positive? *

Yes

Is anyone in your immediate family or household sick or experiencing flu like symptoms? *

Yes

I am certifying that I am OK to work today *

Yes

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This form was created inside of Cape Rail Inc.