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.
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) *
*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
Should be Empty:

GHA Autism Supports Daily COVID-19 Self Declaration Form

If you have any of the COVID-19 symptoms below, STOP! Immediately call your manager!

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