COVID-19 Self-Monitoring Form

COVID-19 Self-Monitoring Form

This self-assessment must be completed each day prior to entering the ICCB’s Springfield office
First Name *
Last Name *
Email *
(Employees should use their ICCB E-mail address)
I am...

ICCB Staff Vistor
To the best of my knowledge ...
- I have no signs of a fever or a measured temperature above 100.3 degrees or greater.
- I do not have any of the following symptoms: cough, sore throat, difficulty breathing or shortness of breath, new or unusual headache, muscle aches, chills, new loss of taste or smell, or vomiting or diarrhea within the past 24 hours.
- I have not had close contact with an individual diagnosed with COVID-19. Close Contact means living in the same household as a person who has tested positive for COVID-19, caring for a person who has tested positive for COVID-19, being within 6 feet of a person who has tested positive for COVID-19 for about 15 minutes, or coming in direct contact with secretions (e.g., sharing utensils, being coughed on) from a person who has tested positive for COVID-19, while that person was symptomatic .
- I have not been asked to self-isolate or quarantine by their doctor or a local public health official.
Self-Assessment *

I CONFIRM that all information above is true I am UNABLE TO CONFIRM the above information is true
Please sign this form in the box below (use your mouse to draw your signature) *

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