COVID19 Employee Self-Certification

I,*
First Last
Confirm:*
I do not have a fever of 100.40 degrees or higher without taking medication to reduce fever.
Confirm:*
I am not currently experiencing any respiratory symptoms (cough and shortness of breath).
Confirm:*
I have not been within close contact (6 feet of a person with a lab-confirmed case of COVID-19 for at least 5 minutes, or had direct contact with bodily fluids of someone who has been confirmed to have COVID-19 (e.g. was coughed or sneezed on))
Have you or anyone in your household traveled outside the state of Ohio in the past 3 days?*
- Yes
- No
Please get with your direct supervisor to discuss what state the travel was to and from and if that state is listed on the positivity rate list from the CDC.
Work Location*
Employee Name*
First Last
Signature*
Today's Date*
MM slash DD slash YYYY
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