Coronavirus Self Declaration Form

Coronavirus Self Declaration Form

For the health and safety of our Woodmeister community, this 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.
Name *

First Name Last Name
What was your body temperature this morning? (In Degrees F) *
Do Not Report to work if your measured temperature is 100.3 degrees or greater.
In light of the COVID-19 pandemic, please do not report to work if you answer "YES" to any of the four health questions 1 through 4 below.
1. Are you experiencing flu-like symptoms including: nasal congestion, sore throat, achiness, nausea, vomiting, diarrhea, signs of a fever or a measured temperature above 100.3 degrees or greater, and cough or shortness of breathe within the past 72 hours? *

Yes No
2. Have you had close contact with an individual diagnosed with COVID-19 or exhibiting flu-like symptoms in the past 14 days? *

Yes No
3. Have you been asked to self-isolate or quarantine by a doctor or a local public health official? *

Yes No
4. Have you been asked to stay at home by a Medical Professional or Board of Health because COVID-19 symptoms were experienced, and you have not been cleared to return to work? *

Yes No
Employer *
Non WM Employees Please list your Company's Name.
Physical Job Location *
Select your Managers Name *
Non-Employees, Please select Non-Employee.
I verify when I am traveling to work WITH OTHER PEOPLE, in a passenger vehicle, truck, plane, ferry or public transit, I consistently wear a mask, and practice social distancing when possible. *

Yes N/A
I acknowledge that the information I've given is accurate and complete. By initialing in this box I am signing this form. *
Thank You Stay Safe
Should be Empty:

Coronavirus Self Declaration Form

In light of the COVID-19 pandemic, please do not report to work if you answer "YES" to any of the four health questions 1 through 4 below.