COVID-19 Return to Work Survey Form
Please complete this survey to help us ensure a safe and healthy workplace for everyone returning to the office.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you experienced any of the following symptoms in the past 14 days?
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
Sore throat
None of the above
In the past 14 days, have you had close contact with anyone diagnosed with COVID-19?
*
Yes
No
Not sure
What is your current COVID-19 vaccination status?
*
Fully vaccinated
Partially vaccinated
Not vaccinated
Prefer not to say
Have you traveled internationally in the past 14 days?
*
Yes
No
Are you currently experiencing any symptoms that could prevent you from working onsite?
*
Yes
No
Date of completing this survey
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Survey
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