EMPLOYMENT INFORMATION

• Fever or Chills
• Cough
• Fatigue
• Nausea or vomiting
• Sore throat
• Headache
• Muscle or body aches
• Diarrhea
• Shortness of breath or difficulty breathing
• New loss of taste or smell
• Congestion or runny nose
• All other symptoms reported by CDC

1. In the past 14 days, I HAVE NOT had any member of my household, any person for whom I provide care, or any intimate partner been diagnosed with or believed to have COVID-19.

2. In the past 14 days, I HAVE NOT been within approximately 6 feet of a person confirmed or believed to have COVID-19 for a few minutes or more.

3. In the past 14 days, I HAVE NOT had direct contact with the bodily secretions of anyone diagnosed with or believed to have COVID-19 (e.g. being coughed on, touching used tissues with a bare hand, sharing food or drink, etc.).

4. In the past 14 days, I HAVE NOT traveled outside the state, excluding commuting from a home location outside of the state, and in particular internationally.

Acknowledgement: I understand that all information collected from me will be kept confidential in the Human Resources Department. This Certification is not a medical diagnosis of COVID-19 and I am not being advised to consult a health care provider or to seek COVID-19 testing unless due to an emergency. My Certification results are solely to determine whether I may report to the worksite.

By using the submit button below, I hereby acknowledge and agree that I have executed this form by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. I understand and agree that I have a right to request and submit a paper copy of this form instead. I understand that I waive such right if I submit this form via electronic transmission. I also understand that I may receive a paper copy of my electronic submission upon my written request to HR@bereanchristianchurch.org.