Health Attestation for Employees of EverybodyFights
I am participating in this company required safety screening program. If any or all of my symptoms are consistent with respiratory illness or the markers of COVID-19, I agree to contact my physician for follow up and report the results to Environmental Health and Safety manager. The responsibility for follow up is mine alone and not those associated with this screening. I hereby release EverybodyFights and each of its employees and agents from any liability arising from or in any way connected with this screening and disclosure form to the fullest extent permitted by applicable law.
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Have you experienced any of the following in the last 24 hours: chills/shaking with chills/loss of taste or smell AND/OR muscle pain, headache, sore throat, nausea, vomiting or diarrhea  combined with a fever, cough, or difficulty breathing? *
Do you have a persistent cough or are you experiencing shortness of breath? *
Have you taken a fever reducer in the last 24hrs with the purpose of relieving a fever of 100.0° or higher? *
Have you taken a cough suppressant in the last 24hrs with the purpose of relieving a dry cough? *
Have you had contact in the last 5 days with someone who has tested positive for COVID-19? *
Have you or someone in your household traveled by air in the last 5 days? *
Have you had “close contact” with an individual diagnosed with COVID-19? “Close contact” means living in the same household as a person who has tested positive for COVID-19, caring for a person who has tested positive for COVID-19, being within 6 feet of a person who has tested positive for COVID-19 for 15 minutes or more, or coming in direct contact with secretions (e.g., sharing utensils, being coughed on) from a person who has tested positive for COVID-19, while that person was symptomatic *
Have you been asked to self-isolate by a doctor or public health official? *
Full Name *
Your Email *
Everybodyfights Location *
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