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

No

1. Are you currently waiting for COVID-19 test results?

Yes

No

2. Within the last 14 days, have you tested positive for COVID-19?

Yes

No

3. Within the last 14 days, have you been exposed to anyone currently waiting for COVID-19 test results?

Yes

No

4. Within the last 14 days, have you been exposed to anyone who has tested positive for COVID-19?

Yes

No

5. Within the last 14 days, have you been exposed to anyone with any of the CDC specified symptoms?

Yes

No

6. Are you experiencing any of the symptoms below?

Yes

No

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

---

8. Have you been fully vaccinated against COVID-19?

Yes

No

a. Has it been 2 weeks or more since the 2nd dose in a 2 dose COVID-19 series?

Yes

No

b. If only 1 dose was required, has it been 2 weeks or more since you received the COVID-19 vaccination?

Yes

No

---

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

Phone Number

Office

BayArea Elk Grove Rancho Cucamonga Roseville Reseda Sacramento Center Based Sacramento School Santa Clarita Lancaster Stockton

Today's date Signature

Submit

---