COVID-19 Self-Certification Form

At the start of each work day at MVCAA, each employee will complete a COVID-19 self-certification. The certification must be clear and complete and submitted prior to going into the office.After reviewing an employee's self-certification, if MVCAAbelieves that an employee is exhibiting one of the COVID-19 symptoms, was exposed to COVID-19 or is unable or unwilling to self-certify, the employee will be asked not to go to the office that day and seek medical attention and any applicable testing by their health care provider, if warranted. Employees may not return to the workplace until cleared by a health care professional or until they are no longer experiencing symptoms for at least 14 days.

I, First Name *

Last Name *

Telephone Number *

Include Area Code

Location *

Fever of 100.4 degrees or greater *

Yes No

Comments re: Fever

Cough within the past 24 hours *

Yes No

Comments re: Cough

Shortness of breath past 24hrs *

Yes No

Comments re: Breath

Sore Throat *

Yes No

Comments re: Sore throat

Any other symptoms associated with COVID-19 (e.g., loss of taste or smell, gastrointestinal problems, such as nausea, diarrhea, and vomiting) *

Yes No

Comments re: other symptoms

Close contact with an individual diagnosed with or exhibiting symptoms of COVID-19 *

Yes No

Comments re: Close contact

Received a positive test result or diagnosis based on symptoms for COVID-19 *

Yes No

Comments re: Positive Test

Directed to self-isolate or quarantine by health care provider or public health official *

Yes No

Comments re: self isolation or quarantine

I certify that the above statements are true and correct.

Signature *

Clear

Date *

Date Hour Minutes AM/PM Option

Please verify that you are human *

COVID-19 Self-Certification Prior to Work Form

Certification