Contractor COVID-19 Health Declaration
Name
Company
Contact Number
Date
Health Screening
Are you currently experiencing any of the following symptoms? (Fever, cough, sore throat, shortness of breath, loss of taste/smell)
No
Yes
Have you tested positive for COVID-19 in the past 14 days?
No
Yes
Have you been in close contact with anyone confirmed or suspected to have COVID-19 in the past 14 days?
No
Yes
Declaration
I declare the information provided is true to the best of my knowledge.
Signature