Employee Attestation Form

Please complete the following screening and attestation form as part of our in person meeting requirements.

Thank you!

Name *

First

Last

Today's Date *

Have you experienced any of the following symptoms of COVID-19 within the past 48 hours? *

• Fever, chills, muscle or body aches
• Cough, shortness of breath or difficulty breathing
• Fatigue
• Headache
• New loss of taste or smell
• Sore throat, congestion or runny nose
• Nausea, vomiting, or diarrhea
• I have not experienced any of these symptoms

Have you tested positive for COVID-19 in the past 10 days?

• No
• Yes

Are you currently awaiting results from a COVID-19 test?

• No
• Yes

In the past 10 days have you been in close proximity to anyone who has been confirmed positive with COVID-19?

• No
• Yes

Thank you. Please click submit below and no further action is required.

Submit