1. You must complete this questionnaire as indicated prior to leaving your home on any day you intend to report to the workplace. These records will be maintained separately from your personnel file. The form will not be submitted until all fields are completed.
2. If you develop symptoms of COVID-19, please stay home and contact Christine Padovano at email@example.com 212-354-8550 x 3318.
3. As a reminder this policy is for the protection of you and your fellow employees. It is mandatory to be completed. Anyone who is in the office without submitting this form will be subject to discipline.
1) I confirm that I have not received a confirmed diagnosis for COVID-19 from a diagnostic coronavirus (COVID-19) test or from a diagnosis by a healthcare professional in the past 10 days.
2) I confirm that I have not experienced any COVID-19 symptoms in the last 10 days (this includes: cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache, sore throat, or new loss of taste or smell).
3) I have taken my temperature today and I can confirm that my temperature is under 100.4 degrees Fahrenheit.
4) I confirm that in the last 14 days, I have not been in close contact with someone with a diagnosis of COVID-19 or who is symptomatic within 48 hours before the onset of the infected or potentially-infected person’s symptoms. (Close contact means 15 minutes of exposure within 6 feet, and/or the infected or potentially infected person is someone you currently live with and/or is someone with whom you have daily interaction).
5) I have not traveled internationally within the past 10 days, or I have traveled internationally within the past 10 days and have completed any applicable quarantine requirements set by the CDC and New York State, available here: update_interim_travel_advisory_april12021.pdf (ny.gov)
Please respond to each individual question. The report can’t be submitted until all fields are completed and you hit submit
If you respond “NO” to any one (or more) of the questions, you are not permitted to report to the workplace and should contact Christine Padovano at firstname.lastname@example.org 212-354-8550 x 3318 for further instruction.
As a reminder this policy is for the protection of you and your fellow employees. It is mandatory to be
completed. Anyone who is in the office without submitting this form will be subject to discipline.