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COVID- SELF-CHECK WITH TEMP

  1. CONFIDENTIAL COVID-19 EMPLOYEE HEALTH SELF CERTIFICATION

    Prior to the start of a work shift, all employees will complete a COVID-19 Employee Health Self Certification. The city will maintain all health information as a confidential medical record in compliance with state and federal law, including but not limited to, the Americans with Disabilities Act, the Fair Employment and Housing Act, and the Confidentiality of Medical Information Act.

  2. 1. Do you have any of the following symptoms? (check if YES)*

    If YES to any, do not enter the workplace. Return home and contact your healthcare provider.

  3. If NO to all, proceed to remaining questions.

  4. 2. Self-Check temperature and check applicable field (**Any temperature 100.4 F or greater is considered a fever):*

    First reading:

  5. Second reading, if necessary:

    **Any temperature 100.4 F or greater is considered a fever. If temperature is above 100.4 F, do not enter the workplace. Return home and contact your healthcare provider.

  6. 3. Have you had close contact with an individual in the past 14 days that is known to be infected with COVID-19?*

    Close contact means within 6-feet or coming in direct contact with secretions (e.g., sharing utensils, being coughed or sneezed on, etc.). The timeframe for having contact with an individual includes the period of time of 48 hours before the individual became symptomatic.

  7. If YES, do not enter the workplace. Return home and contact your healthcare provider.

  8. If NO, proceed to remaining question.

  9. 4. Are you currently under a self-isolation or quarantine order as directed by your doctor or local public health official?*

  10. If YES, do not enter the workplace. Return home and follow the advice of your medical provider.

  11. If NO, to this question and all others, sign below.If NO, to this question and all others, sign below.

  12. Department*

  13. .

    I understand that my employer is relying upon the truthfulness of my certification in permitting me to enter the workplace and that there may be adverse consequences for knowingly false responses. I further understand that if I develop any of the above symptoms, I must separate myself immediately from other employees and notify my supervisor and Human Resources immediately.

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