As we continue to take measures to ensure a safe and healthy work environment during the COVID-19 pandemic,
we ask that you carefully complete this self-assessment.
1Are you experiencing influenza or influenza-like symptoms that include one or all of the following?
Fever (100.4 degrees Fahrenheit or higher)
Chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
2Within the last 14 days, to the best of your knowledge, have you been in close contact with a person who is currently being evaluated for COVID-19 or who has been diagnosed with the COVID-19 virus?
Per CDC guidelines, “close contact“ is defined as being within six feet of someone for a duration of 15 minutes or greater.
3Within the last 14 days, have you been advised to self-quarantine by a local or state health department or health care professional?