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RETURN TO WORK QUESTIONNAIRE
Employee Name
*
Employee PIN:
Branch
*
Administration
Management & Supervision
Burlington
Cedar Rapids
Des Moines
Dubuque
Iowa City
Muscatine
Quad Cities
Waterloo
Other
Email address:
*
Phone number:
*
Facility(ies)
*
SELF DECLARATION
Employees must refrain from returning to work until they are free from fever for 24 hours, without the aid of fever-reducing medication, and until their symptoms have shown improvement.
Have your symptoms resolved or are markedly improved?
Yes
No
Not Applicable
If you had a fever over 100.4 degrees, have you been fever free for 24 hours without the use of fever reducing medication?
Yes
No
Not Applicable
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:
*
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Date Completed:
*
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