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RETURN TO WORK QUESTIONNAIRE

NOTICE

Employees are to self-isolate to prevent the spread of infectious diseases, including COVID-19 and Influenza, and reduce the potential risk of exposure to our workforce, clients, and visitors. To return to work the CDC has provided clear guidance on what needs to occur before leaving isolation. Please do not attempt to return to work if you are not feeling well.

CDC - Return to Work

Employee Name *

Employee PIN:

Branch *

Email address: *

Phone number: *

Facility(ies) *

SELF DECLARATION

Please select the appropriate resonse below which currently apply to you.

Did you have any of the following symptoms?
Check all that apply *

Fever (over 38°C / 100.4°F)

Chills

Cough

Shortness of breath/difficulty breathing

New loss of taste of smell

Fatigue

Muscle aches or body aches

Headache

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

None of the Above

Other Other

What date your symptoms develop? +

Did you see or talk to a medical provider?

Yes

Did they provide you with instructions regarding work?

Yes

If so, what were the instructions?

Were you tested for COVID-19, Influenza, Strep, etc?

Yes

What were you tested for?

Were the test(s) positive?

Yes

If yes, which test(s) were positive?

Covid-19

Influenza

Strep

More than one

If yes, please upload test results here:

Have you been isolated for at least five (5) days since the onset of symptoms?

Yes

Have your symptoms resolved or are markedly improved? (coughing has stopped or has considerably decreased from the onset of symptoms)

Yes

Have you been fever free for 24 hours (without the use of fever reducing medication)?

Yes

Please describe why you were off work? *

EMPLOYEE ACKNOWLEDGMENT

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

Signature: *

clear

Date Completed: * +