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Covid-19 input form Field Champs
Hi Champ, please fill out and submit this form daily to receive your work clearance.
8
Questions
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1
Your Name
*
This field is required.
First Name
Last Name
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2
Your Email
If (it's no must) you add your email here, you will automatically receive a copy of your submission.
example@example.com
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3
Today's Date
*
This field is required.
-
Date
Year
Month
Day
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4
Your Temperature Today
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5
In the past 24 hours have you had...?
*
This field is required.
Cough
Shortness of Breath
Sore Throat
Headaches
Runny Nose
Muscle Pains
NONE OF THE ABOVE
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6
Have you been in contact with anyone recently who has had these aforementioned symptoms (not including your Patient)?
*
This field is required.
YES
NO
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7
Have you been in contact with anyone who has tested positive for Covid-19?
*
This field is required.
YES
NO
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8
Follow the following 5 Obligatory Points Always to keep yourself and your Client safe. After READING below, Click SUBMIT.
.
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