MRSD Self-Attest Form

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MRSD Self-Attest Form

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* Indicates required question

Name: *

Your answer

Date: *

MM

/

DD

/

YYYY

Job Title: *

Your answer

Do you currently have a fever of 99 degrees or higher? *

Yes

No

Do you currently have a cough? *

Yes

No

Do you currently have a headache? *

Yes

No

Do you currently have a sore throat? *

Yes

No

Do you currently have a runny nose and/or congestion? *

Yes

No

Is anyone in your household currently experiencing any of these symptoms? *

Yes

No

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