Coronavirus Self-Declaration Form

A workplace self-reporting form employees use to declare travel history, possible exposure, and any COVID-19 symptoms before returning to the office.

Use this template

Name

Nombre

Apellido

Email

Have you travelled abroad recently?

Yes No

Name of the area(s) visited

Dates of travel

Have you been in contact with people being infected, suspected, or diagnosed with COVID-19?

Yes No

Your relationship with the people and your last contact date with them

Additional Comments

Date

Signature

Sign here

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