Health Compliance Employment Form
Please complete this form to ensure workplace health and safety compliance. All information will be kept confidential and used solely for employment health screening.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Department / Job Title
*
Have you experienced any of the following symptoms in the past 14 days? (Select all that apply)
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
Sore throat
None of the above
Other
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 indicate your current vaccination status for common workplace-required vaccines:
*
Fully vaccinated (all required doses)
Partially vaccinated
Not vaccinated
Prefer not to say
Are you currently under any medical restrictions that may affect your work duties? If yes, please specify.
*
No restrictions
Yes, I have restrictions (please specify below)
If you have medical restrictions, please provide details here:
Signature (Please sign to confirm the accuracy of your responses)
*
Submit
Submit
Should be Empty: