I do not currently have, nor have I had in the last 48 hours, a temperature over 100 degrees. *

True

False

I do not currently have Covid-19. *

True

False

I do not have potential symptoms of Covid-19, such as: Shortness of breath, Persistent Dry cough, Fever, Upset stomach; Nausea, Diarrhea, Vomiting, Sore throat, Headache, Chills, Loss of Taste, or Smell *

True

False

I have not taken medication to reduce fever. *

True

False

There is no one in my household that has Covid-19. *

True

False

I have not traveled to areas with community spread of Covid-19 as defined by the CDC and NY State Department of Health in the last 14 days. *

True

False

No member of my household has returned from travel to areas with community spread of Covid-19 as defined by the CDC and NY State Department of Health in the last 14 days. *

True

False

My household has limited the number of people that we have come in contact with and Are abiding by the “social contract” with the My Little Village Community to prevent the spread of Covid-19 *

True

False

Employee Name *

First Name

Last Name

Date *

MM

DD

YYYY