EMPLOYEE HEALTH DECLARATION

Your health and safety are our top priorities. Please complete this Employee Health Declaration to help us maintain a healthy workplace environment and prevent the spread of illness among our team.

EMPLOYEE INFORMATION

HEALTH INFORMATION

COVID-19 Related Questions:

Have you traveled to a high-risk area within the last 14 days?

• Yes

• No

Have you been in close contact with someone who tested positive for COVID-19 in the last 14 days?

• Yes

• No

Do you currently have any of the following symptoms: fever, cough, shortness of breath, loss of taste or smell?

• Yes

• No

If you answered "Yes" to any of the above questions, please provide details:

General Health Questions:

Do you have any medical condition that may impact your ability to perform your job safely and effectively?

• Yes

• No

If you answered "Yes," please provide details:

Vaccination Status:

Have you been fully vaccinated against COVID-19?

• Yes

• No

If "Yes," please provide the date of your final dose: ________________

If "No," do you intend to get vaccinated?

• Yes

• No

Wellness Programs:

Are you interested in participating in our workplace wellness programs?

• Yes

• No

If "Yes," please specify your areas of interest (e.g., fitness, stress management, nutrition):

Employee Signature:

__________________________

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