Novel (COVID-19) Attestation for Worksite Entry

Name*

First Last

Time Arrived*

:

I have been diagnosed with COVID-19 or am a Person with Symptomatic COVID-19?*

Yes
No

In the last two weeks, I have been in close contact* with someone who has been confirmed to have COVID-19 or is a Person with Symptomatic COVID-19?*

Yes
No

In the last two weeks, I have traveled outside the United States or been on a cruise ship or river boat.*

Yes
No

I am currently experiencing symptoms consistent with COVID-19. Per the CDC, these symptoms include fever, cough, shortness of breath or difficulty breathing, chills or repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.*

Yes
No

*Close Contact - Being within approximately 6 feet (2 meters) of a COVID-19 infected person for at least 15 minutes starting from 48 hours before illness onset until the time the patient is isolated, regardless of the PPE they are wearing.

**Person with Symptomatic COVID-19 – an individual that is displaying COVID-19-like symptoms and that has been directed to testing by a healthcare professional.

If you answered yes to any of the above questions, you may not enter the premises.

Temperature Check Attestation

The CDC has advised employers to keep sick associates or guests at home to limit the transmission of COVID-19. Per the CDC, one of the symptoms of COVID-19 includes fever greater than 100.4°F.

Therefore, to ensure the safety and health of our associates and guests, we are requiring that you have taken your temperature within the last 12 hours and can attest that it is below 100.4°F.

Typing your name below is also your attestation that you are not currently experiencing ongoing cough or shortness of breath.

Name*

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