GHA Autism Supports Daily COVID-19 Self Declaration Form
For the health and safety of our community & those we serve, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs. Complete this form at the beginning of your shift, IMMEDIATELY after clocking in.
If you have any of the COVID-19 symptoms below, STOP! Immediately call your manager!
Work Location (name of site)
Work Location (select from list)
*Failure to answer questions accurately/honestly will result in disciplinary action- (including possible termination)
Have you been in contact with people being infected, suspected or diagnosed with COVID-19?
What type of contact was the exposure?
Same room - did touch
Your relationship with the people and your last contact date with them
Please state whether you've experienced/are experiencing the following. IF YOU ANSWER "YES" TO ANY QUESTIONS BELOW, NOTIFY YOUR MANAGER IMMEDIATELY!
Shortness of Breath
Persistent Pain in the Chest
Loss of taste or smell
Stomach issues / Diarrhea
Please enter your current temperature. IF 99.5 OR HIGHER, CONTACT YOUR MANAGER IMMEDIATELY!
By signing below, I acknowledge that the information I've given is accurate and complete.
Should be Empty: