COVID Self-Certification Screening

Please fill in this form on the day you're planning to be in the buidling

If you answer yes to any of these questions, stay home you will not be permitted to enter the building

Name

Do you have any of the following symptoms:

New fever, chills, muscle or body aches

New cough, sore throat or runny nose

New shortness of breath or difficulty breathing

New fatigue or headache
New loss of taste or smell
New nausea, vomitting or diarrhea

Have you been diagnosed with COVID-19 in the last 10 days?

Have you had close contact with someone who has been isolated or confirmed with COVID-19 in the last 10 days?

Is your temperature today above 100.4 degrees Fahrenheit?