Form
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Are you experiencing any COVID -19 symptoms?
NO
YES
Do you have a fever?
NO
YES
Do you have a cough, muscle pain, chills, headache, recent loss of smell or taste, or sore throat?
NO
YES
Have you been in another state on the CT Travel Ban list since your last check in? If yes please notify the human resource director immediately.
NO
YES
Within the last 14 days, have you come into close contact (closer than 6 ft for 15 minutes or longer) with a person whom you know either has COVID-19 or has exhibited symptoms of COVID-19?
NO
YES
Within the last 14 days, have you been directed or ordered by a health care provider, government entity or other employer to self-quarentine or isolate because of a possible COVID-19 exposure or test result?
NO
YES
Submit
Should be Empty: