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.
If you have any of the COVID-19 symptoms below, STOP! Immediately call your manager!
First Name
*
Last Name
*
Name
First Name
Last Name
Work Location (name of site)
Work Location (select from list)
*
AC Apartment
AJW
All Sites
Burress
Central Office
CF1
CF2
CF3
Cowan
Doby
DP
Durrett
Holbrook
Hollinger
Locust
Lowder
Martin
McGee-Hudson
MGS
Morrell
Morrow Valley
PCA
Potting Shed
RWT
Sundries
Starr
Stickney
Tanglewood
Taylor
*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?
*
Yes
No
What type of contact was the exposure?
Same room - did touch
Hug
Kiss
Event
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
Please enter your current temperature. IF 99.5 OR HIGHER, CONTACT YOUR MANAGER IMMEDIATELY!
*
By signing below, I acknowledge that the information I've given is accurate and complete.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Clear
Submit
Should be Empty: