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GSA Employee Check In
Hi there, please fill out and submit this form. Tim, Mike, Susan, Kevin and HR will be reviewing the encrypted submissions.
5
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1
Name
*
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First Name
Last Name
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2
What locations will you be working from today?
*
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Select more than one if needed.
Home
Field
Ganek Municipal Center/PD
Public Works
Historic Village Hall
Treatment Plant
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3
Check any of the following symptoms you are experiencing
*
This field is required.
Fever
Cough
Shortness of breath or difficulty breathing
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell
None
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4
Do you have a fever?
YES
NO
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5
Do you have a cough?
YES
NO
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6
Are you experiencing shortness of breath?
YES
NO
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7
Have you been exposed to anyone who you have reason to believe has Coronavirus (COVID-19)?
*
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YES
NO
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8
Are you caring for anyone who is sick, with symptoms such as fever, cough, shortness of breath?
*
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YES
NO
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