Healthy at Work

Name*

Enter your first and last name

First Last

Temperature Time*

Enter the time you took your temperature (i.e. 7:00 AM)

:

Recorded Temperature*

Enter your recorded temperature

Symptoms*

Have you had any of the following symptoms since your last day at work or the last day you were in the office? Please select all that apply, or, if none, select None of the Above.

Household Exposure*

Is there anyone in your household who is ill or has been diagnosed with COVID-19?

Yes
No

General Exposure*

Have you been in contact with anyone who is ill, has shown symptoms, or has been diagnosed with COVID-19?

Yes
No

Certification*

By checking this box, I certify that to the best of my knowledge and judgement, the above answers are true and accurate.

I agree

Date*

Please enter the date for which you are completing this form

RESOURCES & TOOLS

RESOURCES & TOOLS