Teaneck Public School Wellness Attestation - Staff/Contracted Staff/Visitors/Vendors

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By acknowledging this waiver, for the period of September 1, 2021 to June 30, 2022, I am attesting that if I exhibit any of the following symptoms, I will not attend work or extracurricular activities that day or as long as the symptoms persist and will notify my immediate supervisor.

At least two of the following symptoms:
- Fever (measure or subjective)
- Chills
- Rigors (shivers)
- Myalgia (muscle aches)
- Headache
- Sore throat
- Nausea or vomiting
- Diarrhea
- Fatigue
- Congestion
- Runny nose

OR At least one of the following symptoms:
- Cough
- Shortness of breath
- Difficulty breathing
- New olfactory disorder (loss of smell)
- New taste disorder (loss of taste)

I will consult with my primary care provider in the event I have one or more of the above mentioned symptoms. I also understand a negative COVID-19 test may be necessary for my return to work. Any updated guidance from the CDC, NJDOH or Teaneck DOH will be shared as appropriate. If I have a chronic condition and exhibit any of the symptoms above, I will notify my immediate supervisor for guidance.

Full Name *

Email *

Phone Number *

Location *

I will stay home and report to my immediate supervisor if I have any close contact (i.e. within 6 feet) of a confirmed infected person for a total of 15 minutes or more over a 24-hour period. *

Yes

I will stay home (if I am unvaccinated) and report to my immediate supervisor when someone in my household is diagnosed with Covid-19, being tested for Covid-19 or has Covid-19 compatible symptoms. *

Yes

I will stay home (if I am unvaccinated) and report to my immediate supervisor if I travel domestically (other than NY, PA, or DE) for longer than 24 hours, in accordance with NJ Department of Health post-travel guidance. *

Yes

I will stay home and report to my immediate supervisor if I travel internationally in accordance with NJ Department of Health post-travel guidance. *

Yes

I will stay home and report to my immediate supervisor if I test positive for Covid-19 *

Yes

By selecting “YES” to this form, I agree to the above statements and I will notify my immediate supervisor in the event there is any change in my personal health or I am unable to attest to the above statements for that work day. *

Yes

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