Waiver Signed for

EMPLOYER / COMPANY COVID SCREENING EXAMPLE

To keep our staff, employees and customers at this locaton safe during the COVID-19 pandemic, we require anyone entering this lcoation to answer to the following questions. 

Have you tested positive for COVID-19 in the last 7 days?   Select option Yes No

Are you vaccinated?   Select option Yes No

Are you waiting for a COVID–19 test or a test result?   Select option Yes No

Have you experienced any flu-like symptoms in the last week?   Select option Yes No

Have you ever tested positive for COVID-19?   Select option Yes No

   I have answered these questions honestly and to the best of my ability.

If you answered yes to any of these questions, please provide details in the notes box below your name and notify our staff.