ESD 112 Safe Start Plan Health Attestation

The health and safety of our staff is important to us. To help ensure the wellness of our ESD 112 team we are required by the state to complete a daily health screening. The form below must be submitted each day that you are on site.

If you have questions about your responses and what to do contact your supervisor or Human Resources (Marnie Allen or Melissa Kreuder) and work from home until the question is resolved.

Staff Name *

First Name Last Name

Staff Email *

Do you have, or have you had, any of the following Class A symptoms in the past 24 hours: fever with a temp of 100.4 or higher; cough; loss of sense of taste and/or smell; or shortness of breath? If you answer yes you must stay home and you are encouraged to contact a medical provider and notify your supervisor and HR. *

Yes No

Do you have, or have your had, any two of the following Class B symptoms in the past 24 hours: fatigue; headache; muscle or body aches; sore throat; congestion or runny nose; nausea or vomiting; or diarrhea? If you answer yes you must stay home and are encouraged to contact a medical provider and notify your supervisor. *

Yes No

Have you tested positive for COVID-19 in the last 10 days or are you currently undergoing COVID-19 testing due to possible exposure or symptoms? If you answer yes you must stay home until cleared to work in person by your supervisor. *

Yes No

Have you been in close contact (within 6 feet for 15 minutes or more over a 24 hour period) with anyone with confirmed COVID-19 in the past 14 days or anyone who is undergoing COVID-19 testing? If you answer yes you must stay home until cleared to work in person by your supervisor or provide proof of vaccination. *

Yes No

Do you or anyone you live with have; or have you or anyone you live with had; any of the following symptoms (Class A) in the last 24 hours? If you answer yes to any of the symptoms below you must stay home and you or the person with the symptom is encouraged to contact a medical provider. *

	Yes	No
Fever, with temp of 100.4 or higher
Cough
Loss of sense of taste and/or smell
Shortness of breath

Do you or anyone you live with have; or have you or anyone you live with had; any two of the following symptoms (Class B) in the last 24 hours? If you answer yes to two or more of the symptoms below you must stay home and you or the person with the symptoms is encouraged to contact a medical provider. *

	Yes	No
Fatigue
Headache
Muscle or body aches
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

Do you or anyone you live with have; or have you or anyone you live with had; in the last 24 hours, only one of the Class B symptoms listed above? If you or someone you live with has or had just one of the Class B symptoms listed above you must stay home until cleared to work in person by your supervisor.

Yes No

Are you currently undergoing COVID-19 testing? If you answer yes you must stay home until cleared to work in person by your supervisor. *

Yes No

Have you been in close contact with someone currently undergoing COVID-19 testing? If you answer yes you must stay home until cleared to work in person by your supervisor. *

Yes No

Have you been in close contact with anyone with suspected or confirmed COVID-19? If you answer yes you must stay home until cleared to work in person by your supervisor. *

Yes No

Within the past 14 days has a public health or medical professional told you to self-monitor, self-isolate, or self-quarantine because of concerns about COVID-19 infection? If you answer yes you must stay home until cleared to work in person by your supervisor. *

Yes No

Do you have a cough that is not caused by another condition? *

Yes No

Do you have shortness of breath or difficulty breathing that is not caused by another condition? *

Yes No

Do you have a fever of 100.4 degrees or higher or a sense of having a fever that is not caused by another condition? *

Yes No

Do you have a sore throat that is not caused by another condition? *

Yes No

Do you have chills that are not caused by another condition? *

Yes No

Do you have a new loss of taste or smell that is not caused by another condition? *

Yes No

Do you have muscle or body aches that are not caused by another condition? *

Yes No

Do you have nausea/vomiting/diarrhea that is not caused by another condition? *

Yes No

Do you have congestion/running nose - not related to seasonal allergies or another condition? *

Yes No

Do you have unusual fatigue that is not caused by another condition? *

Yes No

Does anyone in your household have any of the symptoms in the questions above that are not caused by another condition? *

Yes No

Have you been in close contact with anyone with suspected or confirmed COVID-19? *

Yes No

Have you taken medication to reduce a fever before coming to work? *

Yes No

By electronically signing and submitting this form you are attesting that the answers provided are true and accurate. *

Clear