Employee Self Declaration Form
Employee Name
First Name
Last Name
Department
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please enter the date(s) and reason(s) you will be missing work
Have you travel outside the country after March,2020?
Yes
No
Please write the name(s) of areas you visited and date(s) of travel.
Have you been in close contact with a person diagnosed with, or suspected of being infected by, COVID19?
Yes
No
What is your relationship with that person?
Family member, friend, etc.
Living in the same home?
Yes
No
Last date of contact
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you experienced these symptoms recently?
Rows
Yes
No
Fever
1
2
Cough
3
4
Difficulty breathing
5
6
Fatigue
7
8
Muscle or body aches
9
10
Headache
11
12
New loss of taste or smell
13
14
Sore throat
15
16
Congestion or runny nose
17
18
Nausea or vomiting
19
20
Diarrhea
21
22
Are you requesting use of
College sick time
Time in lieu bank
Vacation entitlement
Personal circumstance leave
Working from home
Not requesting anything
Employment Standards Act such as care of health of a child or immediate family member, compassionate care leave, etc.
Other
I, the employee, agree with the following statements
I declare this is my form and I fill it out as true and accurate.
I understand that Human Resources reserves the right to request additional supporting documentation and may require more detailed documentation in the event of repeated requests.
I understand that the submission of this declaration does not ensure the granting of pay for such absence.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Employee
Submit
Should be Empty: