Return to Work Attestation

Question Title

* 1. Today's Date

Date / Time

Date

Question Title

* 2. Name

Question Title

* 3. Division

Executive Office (4th Floor)

Business Operations (4th Floor)

Education (3rd Floor)

Information Technology (2nd Floor)

Information Technology (1st Floor)

Question Title

* 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.

No

Question Title

* 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.

YES, I attest.