Meat Packing Facility Handler Health Declaration
Full Name
Position/Job Title
Date
Health Status (Please answer the following):
Are you currently experiencing any of these symptoms? (Fever, cough, sore throat, difficulty breathing, vomiting, diarrhea, unexplained rash or lesions)
No
Yes
In the past 14 days, have you been diagnosed with any contagious diseases (e.g., COVID-19, hepatitis, norovirus, etc.)?
No
Yes
In the past 14 days, have you had close contact with anyone diagnosed with a contagious illness?
No
Yes
Are you currently suffering from any wounds, sores, or skin infections on your hands, wrists, or forearms?
No
Yes
Are you currently taking any medication that may impair your ability to perform your duties safely?
No
Yes
Additional Comments
I hereby declare that the above information is true and complete to the best of my knowledge.
Signature
Date