QUOTATION FORM

Date

Name

Do You have any of the following?

Rows	Yes	No	Maybe
Any cold or flu symptoms
Excessive Coughing or heavy chest
Shortness of breath or breathing issues
Sneezing, congested or runny nose
Any illness that would prevent me from carrying out my duties
To the best of your knowledge, have you come into contact with anyone with known case of COVID-19

If you answered 'Maybe' to any of the above, you need to contact management to discuss.

If you answered 'Yes' to any of the above.

Rows	Acknowledge and Agreed
You Must get tested for COVID-19
You must notify Management immediately
COVID-19 Testing will result in you self-isolating until you receive negative result

Comments

By Signing this, I declare that I am fit, healthy and able to carry out my normal duties.

Signature