COVID-19 Health & Attendance Declaration Form
Personal Information
Full Name
Date
Email
Phone Number
Location / Department
Health Screening
In the past 14 days, have you experienced any of the following symptoms?
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
None of the above
Have you been in close contact with a confirmed COVID-19 case in the past 14 days?
Yes
No
Have you tested positive for COVID-19 in the past 14 days?
Yes
No
I declare that the information provided above is true and accurate to the best of my knowledge.