CoVid 19 Attestation

Question Title

* 1. Have you had any of the following symptoms/conditions within the last day that are not caused by another condition:

-A fever of 100.4 or chills
-A cough
-A shortness of breath
-A sore throat th
-Congestion or runny nose
-Fatigue
-Muscle Aches
-A loss of taste or smell
-Nausea or vomiting
-Diarrhea

-Have been in contact with anyone with confirmed COVID-19
-Have you had a positive COVID-19 test for active virus in the past 10 days, or are you awaiting the results of a COVID-19 test?
--Have within the past 14 days had a public health or medical professional tell you to self- monitor, self-isolate or self-quarantine because of concerns about COVID-19 infection.

Yes

No

Question Title

* 2. Measure your current body temperature with a thermometer and enter reading here.

Question Title

* 3. Staff Member Name?

Question Title

* 4. Date of Attestation?