Daily COVID-19 Self Certification
Mass Coastal Railroad
Sign in to Google to save your progress. Learn more
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? *
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. *
Have you been in contact with anyone who is awaiting a test result or someone that has been tested positive? *
Is anyone in your immediate family or household sick or experiencing flu like symptoms? *
I am certifying that I am OK to work today *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Cape Rail Inc.