Northwest COVID-19 Employee Self Assessment
- This tool will help you perform a self-assessment to determine if you are clear to report to work and is based on CDC and ODH guidelines.
- Each employee MUST take the assessment each day before reporting to work.
- Masks are required when onsite, especially in public/common areas or areas that are not your private work space, the exception is if you are medically unable to wear a mask.
- Employees are asked to sanitize their work areas throughout the day and before leaving.

More info: https://coronavirus.ohio.gov/
Email address *
First Name: *
Last Name: *
Today's Date: *
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In the past 24 hours, have you had any of the following NEW symptoms? (If any apply please contact your supervisor)
Have you been within 6ft of a person with a lab-confirmed case of COVID-19 for at least 5 minutes or had direct contact with their mucus or saliva (in the past 14 days)? (If YES, please contact your supervisor) *
Temperature (if greater than 100.3, please contact your supervisor): *
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