COVID-19 Return to Office Declaration
Employee Health and Safety Form
Full Name
Department
Date
Please confirm the following statements regarding your current health status and possible exposure to COVID-19 prior to re-entering the office.
I am not currently experiencing any symptoms associated with COVID-19 (such as fever, cough, shortness of breath, new loss of taste or smell).
I have not been in contact with anyone diagnosed with or suspected of having COVID-19 in the last 14 days.
I have not tested positive for COVID-19 in the last 14 days.
I have not traveled internationally or to a COVID-19 hotspot in the past 14 days.
Other comments (if any):
Signature
Date