Atwell/SCS/RVI Health Assessment Form

Health Assessment Form

The CDC recommendations differ for individuals vaccinated and unvaccinated. Please familiarize yourself with CDC recommendations.

CDC Recommendations
**UPDATED**. Have you completed the NEW 2022 Return to Office and Field Acknowledgement and Safety Pledge?
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Company Email:
No personal emails - use autocomplete to select your email.
Office or Location being visited:
SCS and RVi have their own selections.
What location?
I currently am not experiencing any symptoms of illness and am familiar with and will adhere to the applicable CDC Guidelines
Have you received a positive COVID 19 test in the last 14 days?
Sign here (If on phone or tablet use your finger to sign)
Completion Time

:HourMinutes
Should be Empty: