Staff COVID-19 Check-in

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Please complete this form before you leave home to begin work. Do not wait until you are there to fill this out.

Email *

Your name in full *

Contact phone *

Declaration of health and symptoms status

Penalties apply for providing false information. If you have any symptoms, however mild, you must get tested and isolate until your test results are known.

Please answer all of the following items: *

False

True

I do not have chills or sweats

I do not have a fever

I do not have a cough

I do not have a sore throat

I do not have a runny nose

I do not have loss or change in sense of taste

I do not have loss or change in sense of smell

I do not have shortness of breath

Do you need to stay at home?

If you have answered FALSE to any of the symptoms noted, do not come to work! Please call your supervisor or team leader.

I confirm that YES I am feeling well *

Yes

Required

If you chose NO to the question above

Please contact your supervisor immediately.

In the last 14 days, I have not been in contact with a confirmed case of COVID 19 (except in the course of my employment while wearing the appropriate level of PPE) *

True

False

Required

I am not currently required to self-isolate or self-quarantine. *

True

False

Required

I agree to wear appropriate PPE at all times *

True

False

Required

I will perform hand hygiene at appropriate times *

True

False

Required

If I have COVID-19 symptoms I will get tested and let my manager know. *

Yes

Required

Acknowledgement *

I understand that by adding my name below and submitting this form, that I declare all information provided is true and correct.

Yes

Required

Please type your name below to complete this form and submit. *

A copy of your responses will be emailed to the address you provided.

Submit

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