COVID-19 RETURN TO WORK QUESTIONNAIRE

Quarantining or Self-Isolation is being used to prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce 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 still not feeling well.

Employee Name *

Employee PIN:

Branch *

Email address: *

Phone number: *

SELF DECLARATION

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

Have you been quarantined for fourteen days due to possible contact with a person diagnosed or suspected of COVID-19? * 🛈

Yes

No