COVID-19 Employee Self-Evaluation for On-Campus Work

Employees need to complete this form any day they come to campus.

Required

Name *

First

Last

Email *

What is your temperature? *

Do you have any of the following (please check all that apply) *

Do you work for Krammes? *

Yes No

Have you been in close contact (within 6’) with someone who has a laboratory confirmed Covid-19 diagnosis within the past 14 days? *

If yes, have you been tested?

Date

Year Month Day

Result