Employee COVID-19 Self - Certification
Please complete the following daily before coming to work. If your answer is yes to any of the symptom questions below or your temperature is 100.4 or higher, please contact your administrator or supervisor.

If symptoms are persistent, please contact your medical professional.

If a Co-Vid 19 test is required, stay home until you are provided a result. Contact your administrator or supervisor upon receiving a result to determine the next course of action.

If the symptoms you are experiencing are due to something other than Co-Vid that is a normal condition for you such as allergies or migraine headaches, please discuss with your administrator or supervisor (a medical release documenting the alternate diagnosis may be required). If you have symptoms that prove to be something other than Co-Vid such as a common cold or flu, please discuss with your administrator or supervisor. You may return to work with a medical release according to what the normal criteria is for that condition.

If your answer is yes to having or being in contact with someone with CoVid, you will be asked if this has been in the last 14 days. If in the last 14 days, or if you have not been cleared by County Health or your Medical Professional, contact your administrator or supervisor.

If the temperature is 100.4 or higher, wait up to 1 minute and retake. If your temperature is still 100.4 or higher, please contact your administrator or supervisor.

Employee Last Name *
Employee First Name *
Last 4 Digits of Social Security #
Building *
Do you have a fever, cough, chills and/or muscle aches? *
Do you have a sore throat, runny nose,and/or loss of taste or smell? *
Are you experiencing nausea, vomiting, and/or diarrhea? *
Are you experiencing shortness of breath and/or headache? *
Have you had, had close contact with, lived with, or cared for someone with COVID-19? *
If you have had, had close contact with, lived with, or cared for someone with CoVid-19, has that been in the last 14 days (If yes, contact your administrator or supervisor.) *
Temperature Check (if 100.4 or higher contact administrator or supervisor) *
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