ENMRSH, Inc. COVID-19 Self-Certification Health Screening Form 2021

Employees providing direct care, in-person service coordination, nursing services, developmental instruction, transportation, job coaching are required to wear a mask regardless of vaccination status. This form is required for employees and individuals coming to the Recreation, Education, Development Building.

Continue to:

Wash your hands regularly
Practice social distancing
Take care of yourself!

If you experience fever and/or respiratory symptoms do not report to work. Contact your immediate supervisor for further direction, monitor symptoms, and contact your healthcare provider or the COVID-19 Hotline 1-855-600-3453.

Date *

Date

Name *

First Name Last Name

Job Title *

Supervisor's Name *

Body Temperature Reading (Fahrenheit) *

If you have a fever at or above 100.4 degrees Fahrenheit or are experiencing symptoms of the virus please stay home.

Do you have any new or worsening symptoms of any of the following: *

	Yes	No
Fever
Cough
Shortness of breath
Sore throat
Headache
Muscle Pain
Chills
Repeated shaking with chills
Loss of taste or smell

Notes (optional):

Signature *

Clear