Employee Health - Self Reporting
Name
*
First Name
Last Name
Employee Number
*
Department
*
Phone Number
*
Please enter a valid phone number.
Supervisor's Email
*
example@example.com
Have you experienced any of the following symptoms? Please check all that apply.
*
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
No, I don’t have any of these symptoms
Have you been vaccinated against COVID-19?
*
Fully vaccinated
Partially vaccinated
Not vaccinated
Declines to answer
Date of Positive COVID-19 Test Result
*
-
Month
-
Day
Year
Date of Onset of Symptoms
*
-
Month
-
Day
Year
Date of Return to Work
-
Month
-
Day
Year
If you have been fever free for 24 hours and you are asymptomatic or mildly symptomatic (with improving symptoms) you may return to work on this date.
Upload a copy of your positive COVID-19 test from your healthcare provider. Home testing is not acceptable documentation.
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