ADKX Health Screening Form
Self Attestation for Employees and Visitors

This form must be completed for every day you are on-campus and is to be completed prior to beginning your scheduled shift or your visit to campus.
Full Name *
Date *
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DD
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1. Have you had a recent onset of a dry cough, fever, shortness of breath, muscle aches, or loss of taste/smell? *
2. Have you been in the same room as with a patient with COVID -19 in the last 14 days? *
3. Have you been advised by the health department that you have come into contact with a COVID-19 positive patient in the last 14 days? *
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