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COVID-19 DAILY HEALTH SELF-ASSESSMENT
PLEASE REVIEW DAILY PRIOR TO REPORTING FOR WORK
Start typing in your last name to open the list of names, then select your name.
Section 1: Symptoms
Have you experienced any of the following symptoms in the past 48 hours:
Column A
Column B
Has any information changed?
*ARE YOU FEELING SICK?
If you are sick, you should not attend work in-person. If TWO OR MORE of the fields in Column A are checked off OR AT LEAST ONE field in Column B is checked off, please stay home from work, notify your supervisor of your absence and contact Human Resources/Administration for further instructions.
*SECTION 2: CLOSE CONTACT/POTENTIAL EXPOSURE
Within the last 10 days have you been diagnosed with COVID-19, had a test confirming you have COVID-19, or have been advised to self-isolate or quarantine by your doctor or a public health official? Or are you currently waiting on the results of a COVID-19 test?
Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19?
In the last 2 weeks, did you care for or have close contact (within 6 feet of an infected person for 15 minutes or more) with someone with symptoms of COVID-19, tested positive for COVID-19 or diagnosed with COVID-19? Or have you had direct contact with infectious secretions (e.g., were coughed on)? Or have you traveled to an area of high community transmission?
If ANY of the fields in Section 2 are checked off as YES, please stay home from work, notify your supervisor of your absence and contact Human Resources/Administration for further instructions.
COVID-19 DAILY HEALTH SELF-ASSESSMENT
EMPLOYEE ACKNOWLEDGMENT
I acknowledge that I have received a copy of the COVID-19 DAILY HEALTH SELF-ASSESSMENT. I understand that I am required to review the COVID-19 DAILY HEALTH SELF-ASSESSMENT each day prior to reporting for work. I also understand that if I am sick, experiencing symptoms of COVID-19 or exposed to COVID-19, as described on the COVID-19 DAILY HEALTH SELF-ASSESSMENT, I must stay home from work, advise my supervisor of my absence and contact Human Resources/Administration immediately.

Please enter your personal PIN # to acknowledge your answers.