MRSD Self-Attest Form
Name: *
Date: *
MM
/
DD
/
YYYY
Job Title: *
Do you currently have a fever of 99 degrees or higher? *
Do you currently have a cough? *
Do you currently have a headache? *
Do you currently have a sore throat? *
Do you currently have a runny nose and/or congestion? *
Is anyone in your household currently experiencing any of these symptoms? *
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