Health & Safety Form | erelainc

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In the past three months I have been diagnosed with COVID-19.

Within the last 14 days I have traveled outside of the country and or to another state.

Within the last 14 days I have had close contact with or cared for someone who has been diagnosed with COVID-19 or suspected to have COVID-19

Within the past 24-hours, I have had the following symptoms:

Felt unwell/excessive fatigue

New muscle aches

New headache

Chills

Cough/New Cough

High Fever

Sore Throat

Shortness of Breath

Difficulty breathing

Loss of taste/smell

NONE OF THE ABOVE

If vaccinated, when was the date of the 1st dose?

Date of vaccination

If it's a two dose series, what is the date of the 2nd dose?

Booster date (if any)

What is your temperature?

CONFIRM YOUR ANSWERS

Please make sure you have answered these questions to the best of your ability. Hit submit below when you click the verified box to continue.

I agree that I have answered these questions truthfully and to the best of my ability.

Please answer the following questions to get your COVID protocol approval

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