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* 1. Today's Date

Date

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* 2. Name

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* 3. Division

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* 4. Since your last day of work on-site at the State Board Office, have you experienced any of the following symptoms that you cannot contribute to another health condition?
  • Fever (100.4 F or higher)
  • Cough
  • Shortness of breath
  • Sore throat
  • Muscle aches
  • Respiratory symptoms (runny nose/nasal congestion)
  • Chills or repeated shaking with chills
  • Loss of taste or smell
If you answered YES, to the above question, you do not need to finish completing this survey and MAY NOT work on-site at the State Board Office.  Please stay home and follow your division’s procedure for calling in sick, requesting leave, or requesting to work from home.  Follow the CDC’s guidance on what to do if you are feeling sick and visit DOH’s Covid-19 resource pages for more information. Before returning to work on-site at the State Board Office, you will be required to contact your healthcare provider for medical guidance.

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* 5. I attest that I’ve completed the return to work orientation and that prior to coming in to work on today’s date, that I do not have any of the above symptoms. I understand that if I begin to feel unwell during my time at the State Board Office, I will need to contact the current on-site supervisor to make arrangements to safely exit the building.

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