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2. CONFIDENTIAL COVID-19 EMPLOYEE HEALTH SELF CERTIFICATION
   Prior to the start of a work shift, all employees will complete a COVID-19 Employee Health Self Certification. The city will maintain all health information as a confidential medical record in compliance with state and federal law, including but not limited to, the Americans with Disabilities Act, the Fair Employment and Housing Act, and the Confidentiality of Medical Information Act.
4. 1. Do you have any of the following new or unexpected symptoms that are not considered chronic? (check if YES)*

   1. New cough
   2. Fever or chills
   3. Shortness of breath or difficulty breathing

   1. Muscle or body aches
   2. New loss of taste or smell
   3. Sore throat

   1. Vomiting or diarrhea
   2. NO Symptoms

   If YES to any that cannot be attributed to a chronic condition such as allergies, do not enter the workplace. Return home and contact your supervisor or human resources.

6. If NO to all, proceed to remaining questions.
8. 2. Self-Check temperature and check applicable field (**Any temperature 100.4 F or greater is considered a fever):*

   First reading:

   1. Temperature below 100.4

   1. Fever of 100.4 or above
10. Second reading, if necessary:

    1. Temperature below 100.4

    1. Fever of 100.4 or above

    **Any temperature 100.4 F or greater is considered a fever. If temperature is above 100.4 F, do not enter the workplace. Return home and contact your healthcare provider.
12. 3. Have you had close contact with an individual in the past 14 days that is known to be infected with COVID-19?*

    Close contact means within 6-feet for for a total of 15 minutes or more over a 24-hour period or had unprotected contact with body fluids/secretions (e.g., sharing utensils, being coughed or sneezed on, etc.). The timeframe for having contact with an individual includes the period of time of 48 hours before the individual became symptomatic.

    1. Yes

    1. NO

14. If YES and you are NOT fully vaccinated, do not enter the workplace. Return home and contact your healthcare provider.

    YOU ARE NOT REQUIRED TO QUARANTINE (you are exempt) if you do not have symptoms AND you are up to date on your COVID-19 vaccines. This means that you are either fully vaccinated and boosted or you are fully vaccinated but not yet eligible for a booster. You must monitor your health for symptoms of COVID-19 for 14 days following close contact. In addition, it is recommend you get tested 5-7 days after exposure.

16. If NO, proceed to remaining question.
18. 4. Are you currently under a self-isolation or quarantine order as directed by your doctor or local public health official?*

    1. Yes

    1. No

20. If YES, do not enter the workplace. Return home and follow the advice of your medical provider.

22. First Name*
23. Last Name*
25. Department*

    1. Recreation
    2. Senior Center
    3. Police Department
27. .

    1. I certify that my responses are truthful and accurate to the best of my knowledge.

    I understand that my employer is relying upon the truthfulness of my certification in permitting me to enter the workplace and that there may be adverse consequences for knowingly false responses. I further understand that if I develop any of the above symptoms, I must separate myself immediately from other employees and notify my supervisor and Human Resources immediately.
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