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COVID-19 RETURN TO WORK QUESTIONNAIRE

Employees are to self-isolate or quarantine to prevent the spread of infectious diseases, including COVID-19, 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.

Employee Name *

Employee PIN:

Branch *

Email address: *

Phone number: *

Have you been vaccinated for COVID-19? *

Yes

Have you submitted your vaccination card to Human Resources?

Yes

Submit your COVID-19 vaccination card

SELF DECLARATION

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

Were you off due to an illness or did you develop any symptoms?

Yes

If you checked YES above to symptoms developing, when did your symptoms develop? +

If yes, 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

Other Other

Were you tested for COVID-19? *

Yes

If yes, was the test positive?

Yes

If yes, please upload test results here:

Have you been isolated for at least ten (10) 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

Have you been vomit free / diarrhea free for 24 hours?

Yes