Self Attestation
This form must be completed daily by each employee scheduled to work over the summer.  Preferably, this should be done prior to entering your work location.  If you are unable to complete this prior to arrival, you must complete this form before you start your work day.  

When completing the attestation, if you answer "YES" to any of the numbered screening questions, you MUST remain out of work and contact your supervisor immediately.  DO NOT COME INTO WORK.

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Your Name (last, first) *
What is your home building? *
Are you going to be absent today? *
1) In the last 14 days, have you received a confirmed diagnosis for COVID-19 by a COVID-19 test or from a diagnosis by a health care professional? *
2) In the last 14 days, have you: Traveled internationally or returned  from a state that was on the restricted list as of the date you returned? *
3) In the last 14 days, have you had close contact with or cared for someone currently diagnosed with COVID-19? *
4) In the last 14 days, have you experienced any cold or flu-like symptoms (to include fever, cough, shortness of breath or difficulty breathing, sore throat, pressure in the chest, extreme fatigue, earache, persistent headache, diarrhea, vomiting, muscle pain, chills, repeated shaking with chills, and persistent loss of smell or taste)? *
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