Covid Daily Self-Certification Form

  • This form must be submitted by every employee, every day prior to "punching in" for their scheduled shift.

    Failure to self-certify or falsely checking any box is grounds for disciplinary action up to and including termination

  • Choose the location where you are punching in for today.
  • Today's Date:
  • Common COVID-19 Symptoms

    Temperature higher than 100.3 degrees Fahrenheit Headache
    Cough Sore throat
    Congestion/Runny Nose New loss of taste or smell
    Shortness of breath or difficulty breathing Muscle and body aches
    Chills Diarrhea
    Fatigue Nausea and/or vomiting
    Any other COVID-19 symptoms identified by the Centers for Disease Control (CDC)
  • Check each box that you can truthfully and honestly attest to be true, out of the respect for the health, safety and well-being of your co-workers and customers. If you are unable to check one or more of these boxes, please contact HR or your manager.
  • This field is for validation purposes and should be left unchanged.

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