1. Name*

2. Do you have or recently had a fever in the last 14 days?NoYes

3. Do you have difficulty breathing or have shortness of breath?NoYes

4. Do you have a cough?NoYes

5. Do you have flu-like symptoms, such as headache or fatigue?NoYes

6. Have you experienced recent loss of taste or smell?NoYes

7. Have you been in contact with any positive confirmed Covid-19 patients in the last 14 days?NoYes

8. Have you been in contact with anyone feeling ill in the last 14 days?NoYes

9. Have you traveled outside of the US in the past 14 days or have been on a plane in the past 7 days?NoYes

10. I will wear all necessary PPE and socially distance while at work. If I have any COVID-19 symptoms or come in contact with someone that has or may have COVID, I will report it immediately and not report to work.I UNDERSTAND

By submitting this application you are electronically signifying that the above information is true and that you agree with the terms of submission.