Health declaration: SOA_03.01.005
Certain symptoms are indicative of food borne diseases. Please complete the following health declaration. If you have any of the following symptoms or are in contact with the below listed carriers of food borne illnesses, please immediately signal this to the personnel manager.
Name
First Name
Last Name
Email
example@example.com
Date
-
Month
-
Day
Year
Date
I have experienced the following(check all that apply)
*
Diarrhea for several days in recent months
Sore throat with a fever more than three times in the past year
A persistent cough that lasts three weeks after a cold
Coughing up phlegm daily
Red, swollen or tender cuticles
Sores on my hands
Any rashes or eczema
Regular contact with turtles, snakes, chickens, birds, dogs, or cats
None of the above
I declare myself to be healthy and fit for work.
Yes
No
Signature
Submit
Should be Empty: