THSH Daily Employee Health Certification Form

Full Name

(a) Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19?

Yes

(b) Have you tested positive for COVID-19 in the past 14 days?

Yes

If you answered yes to any of the above questions, do not go to the office. Contact Lisa Maline at (631)-404-0971. You are required to notify Lisa Maline at (631) 404-0971 immediately if your answers to the above questions change at any time, such as if you start to experience any symptoms of COVID-19. Symptoms of COVID-19 include, but are not limited to: cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, sore throat, or new loss of taste or smell.

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THSH Daily Employee Health Certification Form

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