Coronavirus COVID-19 Self-Declaration Form

Coronavirus COVID-19 Self Declaration Form
Personal*

First NamePhoneEmail
Have you been in any overseas countries in the last 15 days or are you coming from any overseas airport?

YesNo
In the last 15 days, have you had contacts with someone who has been in overseas countries affected and had symptoms such as cough and / or fever?

YesNo
Have you had any of the following symptoms in the past 15 days? - Temperature rise above 37.2 °

YesNo
Cough

YesNo
Worsening of general physical conditions

YesNo
I hereby undertake to inform if, in the next few days, I find any health problems related to "Coronavirus - Covid 19", so that the company can carry out further checks with the people I met.
Date date
Signature date
Should be Empty: