DO Staff Self-Certification Form

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Please answer the following questions before reporting to work. Your responses must be reviewed by a staff member before you may begin work.

First Name *

Last Name *

I am self-certifying that I have the following symptoms. Please check all that apply. *

Fever (100.4 degrees or higher)

Cough

Shortness of breath

Sore throat

Headache

Body aches

Diarrhea

Vomiting

New loss of taste or smell

I do not have any of the above symptoms

Required

I am exhibiting one or more symptoms of COVID-19 but am not suspected of having COVID-19 and have provided a physician's note to release me to work. *

Yes

I have returned from international travel or a hotspot in the last 14 days. *

Yes

I am self-certifying that to my knowledge: *

I have not been exposed to someone suspected of or showing symptoms of COVID-19 in the last 14 days.

I have been exposed to someone suspected of or showing symptoms of COVID-19 in the last 14 days.

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