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 Name
Last Name
Work Location (name of site)
Work Location (select from list)
*
Please Select
AC Apartment
AJW
All Sites
Burress
Central Office
CF1
CF2
CF3
Cowan
Doby
DP
Durrett
Holbrook
Hollinger
Lowder
Martin
McGee-Hudson
MGS
Morrell
Morrow Valley
PCA
Potting Shed
Remote (working from home)
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
Currently (Today) or in the past 24 hours, have you had ANY of the following symptoms? (Mark all that apply)
Allergy or Cold symptoms
Sore Throat
Congestion, Sinus pressure, or Runny Nose (lasting > 24hours)
Cough
Fever or feeling feverish (Chills/sweating)
Headache (not typical- significant/unexplained)
Shortness of Breath or New Trouble breathing
Chest Pain or Chest Tightness
Muscle or Body Aches
Vomiting or Diarrhea
Extreme Fatigue (being more tired than normal)
Loss of Taste or Loss of Smell
NONE (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 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
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
*
-
Month
-
Day
Year
Date
Signature
*
Clear
Submit
Should be Empty: