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COVID- 19 Daily Wellness Questionnaire for Town Employees

  1. 1. Are you experiencing flu-like symptoms including: nasal congestion, sore throat, achiness, nausea, vomiting, diarrhea, signs of a fever or a measured temperature above 100.3 degrees or greater, new loss of sense of smell or taste, and cough or shortness of breath within the past 72 hours?
  2. 2. Have had close contact with an individual diagnosed with COVID-19 or exhibiting flu-like symptoms in the past 14 days?
  3. 3. Have you been asked to self-isolate or quarantine by your doctor or a local public health official?
  4. 4. Have you been asked to stay home by a Medical Professional or Board of Health because COVID-19 symptoms were experienced, and you have not been cleared to return to work?
  5. Electronic Signature Agreement*
    I understand that I will inform my Supervisor immediately if I answered ‘Yes’ and if required will provide medical certification to be able to return to work.
  6. Please use your assigned Pin Number. If you don't have one contact Human Resources at or 508 693 3554 ext: 149
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  8. This field is not part of the form submission.