COVID-19 Daily Survey

Contact Name(*)

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Email(*)

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Contact Phone(*)

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COVID Survey Date(*)

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I have NOT had any COVID-19 symptoms in past 14 days(*)

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See CDC symptoms list: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

I have NOT had a positive COVID-19 test in past 14 days(*)

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I have NOT been in “close contact” (defined as being within 6’ for 15 minutes) with confirmed or suspected COVID-19 case in past 14 days(*)

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PLEASE NOTE: Only if you have answered TRUE to each of these statements may you come to work today.

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