COVID-19 Accommodation

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* 1. Full Name

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* 2. Today's Date:

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* 3. Phone Number:
The Medical Director will contact you within 48 hours.  Please enter a good phone number where you can be reached.

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* 4. Email:
The Medical Director will email you a form you can use to electronically attest that you meet requirements to return to work.  Please enter an email so you can fill out the form.

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* 5. Supervisor's name

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* 6. Department

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* 7. Have you had any NEW symptoms in the past week?
Select all that apply.  Don't include symptoms you already had for allergies, COPD, IBS, etc.

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* 8. Within the past 14 days, have you been in close physical contact (6 feet or closer for a least 15 minutes) with a person who is known to have laboratory-confirmed COVID-19 or with anyone who has any symptoms consistent with COVID-19?

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* 9. Are you currently waiting on the results of a COVID-19 test?

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