Grocery Deli Counter Staff Health Form
Full Name
Date
Shift
Health Questions
Are you currently experiencing any of the following symptoms? (Fever, cough, sore throat, shortness of breath, loss of taste or smell)
No
Yes
Have you been in contact with anyone diagnosed with a communicable illness in the last 14 days?
No
Yes
Have you been asked to self-isolate in the past 14 days?
No
Yes
Declaration
Signature