Employee Health Declaration Form
Employee Name
Employee ID
Department
Date
1. Are you currently experiencing any of the following symptoms?
Fever
Cough
Sore Throat
Difficulty Breathing
Other
2. Have you had close contact with a confirmed COVID-19 case in the past 14 days?
Yes
No
3. Have you traveled internationally in the last 14 days?
Yes
No
4. Other relevant health information
Signature
Date