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* 1. Employee ID

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* 2. Today's Date and Time

Date
Time

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* 3. Within the last 14 days, have you been in close contact with any person who has a confirmed case of Coronavirus (COVID-19)?

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* 4. Within the last 14 days, have you been in close contact with any person who is suspected of having Coronavirus (COVID-19)?

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* 5. Do you have any of the following symptoms: FEVER, COUGH, DIFFICULTY BREATHING, or SORE THROAT

By entering your Employee Identification number, you hereby confirm to the best of your knowledge that you are not infected with the Coronavirus (COVID-19). If you are having any of the symptoms above, have been diagnosed as having Coronavirus (COVID-19) or have reason to believe that you have been in contact with someone that is infected, do not come to work! Instead contact your manager or HR.
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