COVID-19 Self-Certification

CALIFORNIA CONSUMER PRIVACY ACT NOTICE: We are collecting this personal health information to help reduce the risk of spreading the COVID-19 virus, and to comply with our legal obligations to provide a safe workplace. We will maintain the confidentiality of this information as appropriate. We appreciate your cooperation during this unprecedented crisis

If you are responding for a child, please answer the following question as it pertains to your child

Symptoms (Select what applies)
Fever or chills ,Cough , Shortness of breath or difficulty breathing , Tiredness , Muscle or body aches , Headache , New loss of taste or smell , Sore throat , Congestion or runny nose , Nausea or vomiting , Diarrhea , Stomach ache , Poor appetite or poor feeding , None of the above


I, in behalf of , attest that I have answered all questions truthfully and to the best of my ability.

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