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

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 *
 
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Did you see or talk to a medical provider?
Did they provide you with instructions regarding work?
Were you tested for COVID-19, Influenza, Strep, etc?
Were the test(s) positive?
If yes, which test(s) were positive?

Have you been isolated for at least five (5) days since the onset of symptoms? 
Have your symptoms resolved or are markedly improved? (coughing has stopped or has considerably decreased from the onset of symptoms)
Have you been fever free for 24 hours (without the use of fever reducing medication)?

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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