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* Name:


*required information

If you answer "Yes" to any of the questions you may not report to work.

* 1. Have you experienced a fever over 100.4 degrees F or greater, a new cough, new loss of taste or smell or shortness of breath within the past 10 days?
Yes
No
* 2. In the past 10 days, have you gotten a positive result from a Covid-19 test that tested saliva or used a nose throat swab? (not a blood test)
Yes
No
* 3. To the best of your knowledge, in the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone while they had Covid-19?
Yes
No

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