Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

DRAFT - Daily PT Seasonal Staff Health Screen

  1. Have you been in close contact with anyone who has tested positve for or had sympotms of COVID-19? (close contact means being with 6 feet for more than 10 mins) ?*

  2. Have you traveled internationally or out-of state to any state beyond the border states (NJ, CT, PA, MA, VT), for more details about travel restrictions.*

  3. In the past 24 hrs, have you experienced any COVID-19 related symptoms such as: *

    Fever of 100 F or higher or chills; dry Cough or congestion (unrelated to allergies); shortness of breath or trouble breathing (unrelated to asthma & exercising); nausea, vomiting or diarrhea; or loss of taste or smell

  4. In the last 24 hours, have you tested positive for COVID-19?*

  5. If you selected more than None or neither, please stay at home, contact Jim or Yolanda and look for a sub to cover your shift and contact your healthcare provider for further guidance.

  6. Please confirm you read all of the above questions and answered to the best of your knowledge by placing your initials in the box. Then "submit" this form.

  7. Leave This Blank:

  8. This field is not part of the form submission.