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 of the questions below, you must NOT report to work at a County work location until you are cleared to return to work pursuant to the WCPC’s Preparedness Plan and Working Safely Protocols. If you are approved by your supervisor to work remotely, you should do so until cleared to return to any County worksite. 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

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* 3. Have you been in contact with anyone who tested positive for COVID-19 within the past 14 days?'

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* 4. Have you had close contact with and/or live or cohabitate with any person displaying COVID-19 symptoms, such as fever, cough, shortness of breath, sore throat, new loss of smell or taste, and/or gastrointestinal problems, including nausea, diarrhea and vomiting?

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