Here is a sample image of the online form
Reported on behalf of Employee Name:
Please fill in all fields, including today’s date, your temperature and any symptoms you may be experiencing. You may choose more than one symptom.
In the past two weeks, have you TESTED positive for COVID-19? Or, were you living with or had close contact with someone who has TESTED positive for COVID-19? (Yes or No)
Select all NEW symptoms that you are experiencing. You do not have to select symptoms related to pre-existing conditions, other known conditions diagnosed by a doctor, such as an infection, or seasonal allergies.
- Shortness of Breath / Difficulty
- Body or Muscle Aches
- Sore Throat
- Nausea, Vomiting or Diarrhea
- Loss of taste or smell
Describe other symptoms:
I certify the information is true.
Submit the Form