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.
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.  
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? *


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

Signature: *