This survey must be completed before arriving at work.

EMPLOYEE CERTIFICATION OF LACK OF EXPOSURE

In accordance with Wayne County Probate Court’s Working Safely During COVID-19 Protocols, Wayne County Probate Court employees must complete this daily screening form PRIOR TO reporting to work. If you answer “Yes” to any question (except for question #3) of this survey, you must NOT report to work at a County work location until you are cleared to return to work pursuant to the WCPC’s Return to Work Protocols. To help ensure your safety we ask that you complete this survey honestly and accurately.

The purpose of this survey is to determine whether you or a visitor to or member of your household poses a heightened risk of exposing employees to the novel coronavirus/COVID-19 and therefore whether you will be allowed access to Wayne County Probate Court.

Please also note that this information will be kept confidential and will not be released to any third parties without your consent in writing. Please also note that this information will be kept in your file marked confidential to only be seen by Human Resources and the Probate Court Pandemic Response Team.

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* 1. What is your name?

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* 2. Today's Date

Date

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* 3. Have you been fully vaccinated (two weeks have passed since last dose)? Must be on file with HR

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