DAILY CHECK QUESTIONNAIRE for ESSENTIAL WORKERS - FOR COVID-19

As an essential worker who has been potentially been exposed to COVID-19, traveled to an area known to have substantial community spread or tested negative for COVID-19 but advised to quarantine, you will need to record the following information daily for the 14-days following potential exposure.
 
DISCLAIMER:
Please be assured your medical information will remain confidential. The information provided in this form will be kept separate from any personnel information and is limited to those who need-to-know.  This information will not be kept longer than required by law.  
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Did you take your temperature today? *
Do you have any new or unexpected symptoms to report? These may include: Fever or feeling feverish (chills, sweating), New cough, Difficulty breathing, Sore throat, Muscle aches or body aches, Vomiting or diarrhea or New loss of taste or smell * 🛈
Do you agree to wear a mask or face covering at all times while at work? *
Do you agree to maintain 6 foot minimum social distancing from coworkers and client workers at all times? *
Do you agree to disinfect and clean workspaces and equipment regularly and will not share PPE with anyone? *
Do you agree to leave work immediately if you develop any new symptoms while at work? *
Do you agree to notify HR (800-249-6161 or humanresources@mjsia.com) if you develop any new symptoms while at work? *

EMPLOYEE ACKNOWLEDGMENT

I agree that the information I am providing is true and accurate to the best of my knowledge.

Signature: *
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