Please complete and submit the form below prior to entering the building each day to come to the office.
Fever of 100° F or greater [38.0° C]*
Yes
No
Severe shortness of breath or difficulty breathing*
New loss of smell and/or taste*
Extreme fatigue*
Persistent chills*
Persistent cough*
Prolonged muscle aches and pains*
Sore throat*
In the past two weeks, have you tested positive for COVID-19?*
In the past two weeks, have you been in close contact with anyone who has tested positive for COVID-19?*
In the past two weeks, have you exhibited any of the symptoms of COVID-19 listed above?*
In the past two weeks, have you been in close contact with anyone who has exhibited any symptoms of COVID-19?*
In the past two weeks, have you traveled abroad?*
I attest that the foregoing information is true and correct.*
Agree
Important Note: If you have answered “Yes” to any of these questions please contact your direct manager or HR. Do not enter the building.