GHA Autism Supports Daily COVID-19 Self Declaration Form

GHA Autism Supports Daily COVID-19 Self Declaration Form

For the health and safety of our community & those we serve, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs. Complete this form at the beginning of your shift, IMMEDIATELY after clocking in.
First Name*
Last Name*
Name

First NameLast Name
Work Location (name of site)
Work Location (select from list)*
*Failure to answer questions accurately/honestly will result in disciplinary action- (including possible termination)
Have you been in contact with people being infected, suspected or diagnosed with COVID-19?

YesNo
Currently (Today) or in the past 24 hours, have you had ANY of the following symptoms? (Mark all that apply)

Allergy or Cold symptomsSore ThroatCongestion, Sinus pressure, or Runny Nose (lasting > 24hours)CoughFever or feeling feverish (Chills/sweating)Headache (not typical- significant/unexplained)Shortness of Breath or New Trouble breathingChest Pain or Chest TightnessMuscle or Body AchesVomiting or DiarrheaExtreme Fatigue (being more tired than normal)Loss of Taste or Loss of SmellNONE (I don’t have any symptoms)
If you currently have or have had any of the above listed symptoms in the past 10 Days, do NOT begin your work shift- Contact your Manager immediately!
What type of contact was the exposure?

Same room - did touchHugKissEvent
Your relationship with the people and your last contact date with them

Please state whether you've experienced/are experiencing the following. IF YOU ANSWER "YES" TO ANY QUESTIONS BELOW, NOTIFY YOUR MANAGER IMMEDIATELY!*

	Yes	No
Fever
Cough
Shortness of Breath
Persistent Pain in the Chest
Loss of taste or smell
Congestion
Upset stomach
Stomach issues / Diarrhea
Sore throat

Check your current temperature. IF 99.5 OR HIGHER, CONTACT YOUR MANAGER IMMEDIATELY and DO NOT BEGIN YOUR WORK SHIFT!
Check your current temperature. IF 99.5 OR HIGHER, CONTACT YOUR MANAGER IMMEDIATELY and DO NOT BEGIN YOUR WORK SHIFT!
By signing below, I acknowledge that the information I've given is accurate and complete.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

GHA Autism Supports Daily COVID-19 Self Declaration Form

*Failure to answer questions accurately/honestly will result in disciplinary action- (including possible termination)

If you currently have or have had any of the above listed symptoms in the past 10 Days, do NOT begin your work shift- Contact your Manager immediately!

Check your current temperature. IF 99.5 OR HIGHER, CONTACT YOUR MANAGER IMMEDIATELY and DO NOT BEGIN YOUR WORK SHIFT!