COVID-19 HEALTH FORM Please enable JavaScript in your browser to complete this form.Name *FirstLastStudent/Employee ID Number *Are you in good health? *YesNoDo you think you have a temperature above 100 degrees? *YesNoYou can still report to work/school as long as your temperature is below 100.0, and no subjective fever or any other signs of illness.What is your temperature?You can still report to work/school as long as you temperature is below 100.0, and no subjective fever or any other signs of illness.Have you been feeling sick? *YesNoDo you have any of the following symptoms?CoughSore ThroatShortness of BreathCongested/Runny Nose*ChillsUnexplained Muscle Aches*different from pre-existing allergiesHeadachesUnexplained FatigueAbdominal PainNausea or VomittingDiarrheaLoss of Smell or TasteAre you vaccinated?YesNoHave YOU tested postive for COVID-19 in the last 30 days? *NoYesWhat date did YOU test positive for COVID-19?Has ANYONE YOU LIVE WITH tested positive for COVID-19 in the last 30 days?NoYesAre you self quarantined?YesNoDate YOU started your self-quarantine?Other Health IssuesContact Phone Number *Signature *Clear SignatureCommentSubmit Please enable JavaScript in your browser to complete this form.Name *FirstLastStudent/Employee ID Number *Are you in good health? *YesNoDo you think you have a temperature above 100 degrees? *YesNoYou can still report to work/school as long as your temperature is below 100.0, and no subjective fever or any other signs of illness.What is your temperature?You can still report to work/school as long as you temperature is below 100.0, and no subjective fever or any other signs of illness.Have you been feeling sick? *YesNoDo you have any of the following symptoms?CoughSore ThroatShortness of BreathCongested/Runny Nose*ChillsUnexplained Muscle Aches*different from pre-existing allergiesHeadachesUnexplained FatigueAbdominal PainNausea or VomittingDiarrheaLoss of Smell or TasteAre you vaccinated?YesNoHave YOU tested postive for COVID-19 in the last 30 days? *NoYesWhat date did YOU test positive for COVID-19?Has ANYONE YOU LIVE WITH tested positive for COVID-19 in the last 30 days?NoYesAre you self quarantined?YesNoDate YOU started your self-quarantine?Other Health IssuesContact Phone Number *Signature *Clear SignatureWebsiteSubmit Contact For any inquiries please email or call info@firstfiveems.com 773-741-3042 Facebook-f Instagram Youtube Twitter
