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Employee Health Declaration Form

Date

Temperature: *

First Name *

Last Name *

Have you recently traveled (within last 14 days) to an area with community transmission? Type YES or NO *

Have you had recent contact with a COVID-19 area or persons? Type YES or NO *

Have you had symptoms including fever or signs/symptoms of lower respiratory illness including cough or shortness of breath? YES or NO *

Acknowledgement *

I hereby acknowledge the above symptoms and understand the potential health risks associated with unintentional exposure to the COVID-19 virus.

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