Healthy at Work

  • Enter your first and last name
  • Enter the time you took your temperature (i.e. 7:00 AM)
  • Enter your recorded temperature
  • 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.
  • Is there anyone in your household who is ill or has been diagnosed with COVID-19?
  • Have you been in contact with anyone who is ill, has shown symptoms, or has been diagnosed with COVID-19?
  • Please enter the date for which you are completing this form
    MM slash DD slash YYYY