STAFF COVID-19 Symptom Report
Please complete this form daily PRIOR to reporting to your work location.
Staff First Name *
Staff Last Name *
Work Location/Department *
Required
In the last 24 hours, have you experienced any of the following symptoms in a way not normal to you? (Fever or chills, Cough, Shortness of Breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea) *
If you are experiencing any of the above symptoms in a way not normal to you, please stay home and contact your direct supervisor. *
Required
In the last 14 days, have you been in close contact with a suspected or confirmed case of COVID-19 or tested positive yourself? *
If you have been in close contact with someone with a suspected or confirmed case of COVID-19 or have tested positive yourself, please stay home and contact your direct supervisor. *
Required
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