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Name*

First Last

Phone*

Shift Date*

Shift Start Time*

: HH

MM

Shift End Time*

: HH

MM

In the past 24 hours, have you experienced:

Have you recently been in close contact with anyone who has exhibited any symptoms?*

Have you recently been in contact with anyone who has tested positive for COVID-19?*

Have you recently traveled to a restricted area that is under a Level 2, 3, or 4 Travel Advisory according to the U.S. State Department?*

Including: China, Italy, Iran and most countries in Europe.

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