Coronavirus Self Declaration Form

Coronavirus Self Declaration Form

For the health and safety of our community, this declaration of illness is required. In light of the COVID-19 pandemic, please do not report to work if you answer "YES" to any of the following questions. 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
WM Employee ID or Outside Company Name *
Please use Entire Employee ID, for Example XXX###
Physical Job Location *
What was your body tempature this morning? (In Degrees) *
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
5. Have you traveled to work with other people in a passenger vehicle, ferry or bus? This Question Applies only to people working on Nantucket or Martha's Vineyard *

Yes No NOT APPLICABLE
Select your Managers Name *
Non-Employees, Please select Non-Employee.
Date *

Month Day Year
Date
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
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