Health Safety Self Declaration
Please complete this form to declare your health status for safety purposes.
Full Name
*
First Name
Last Name
Date of Declaration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you experienced any of the following symptoms in the past 14 days?
*
Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea
Have you been in close contact with anyone diagnosed with a contagious illness in the past 14 days?
*
Yes
No
Have you traveled internationally in the past 14 days?
*
Yes
No
Please provide any additional information relevant to your health status.
Submit
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