Fillable WEEKLY COVID-19 SYMPTOMS SCREENING ATTESTATION FORM FOR ASA (ASA College)

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WEEKLY COVID-19 SYMPTOMS SCREENING ATTESTATION FORM FOR ASA (ASA College)

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WEEKLY COVID-19 SYMPTOMS SCREENING ATTESTATION FORM
FOR ASA EMPLOYEES
LAST, FIRST NAME: _____________________, _____________________
EMAIL ADDRESS: _____________________@asa.edu
EMPLOYEE ID#: ___________________
DEPARTMENT NAME:
____________________________
CAMPUS: ______________________
FLOOR: ________
DAY AND TIME: _________________________________________________
Symptom Screening and Tracking: This self-screen must be performed by employees before going to the office or class
and before starting work. In conducting the self-screen, employees must answer the following five (5) questions on a daily basis:
1. In the past 14 days, have you knowingly been in close contact with anyone who has tested
positive for COVID-19 or has symptoms of COVID-19?
YES NO
2. In the past 14 days, have you tested positive for COVID-19?
YES NO
3. Do you currently have a temperature of 100 degrees Fahrenheit or higher?
YES NO
4. Do you have today, or have you had in the past 14 days any one, or more of the following symptoms:
DATE
Mon.
Tues.
Wed.
Thurs.
Fri.
Sat.
Fever or Chills
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Cough, Difficulty Breathing
or Shortness of Breath
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Sore Throat, Congestion or
Runny Nose
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Nausea or Diarrhea
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Fatigue, Muscle Pain or
Body Ache
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
New Loss of Taste or Smell
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
Headache
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES NO
5. Have you traveled outside of the States of New York, New Jersey, Pennsylvania, or
Connecticut within the last 14 days?
YES NO
Page 2 of 2
Instructions:
If you answered NO to all of the boxes above, submit this form on a weekly basis.
If you answered YES to any of the questions above:
1. DO NOT COME TO ANY ASA CAMPUSES. Stay home and contact your healthcare provider. You can return only
when cleared by your healthcare provider, with a note stating so, and 2 negative COVID-19 tests.
2. As soon as you have any of the above symptoms notify your supervisor via phone and email that you will be absent
from work.
3. Follow the CDC’s What to Do If You are Sick guidelines:
https://www.cdc.gov/coronavirus/2019ncov/if-you-are-sick/steps-when-sick.html
I, _______________________________, employee of the ASA College, hereby affirm that the above answers
(Employee Name)
are correct and true, to the best of my knowledge.
I understand that providing this information is for the health and safety of myself and my fellow students, ASA College
faculty and coworkers/staff.
I understand that if I must answer YES to any of the above, that said answer, by itself, will not be grounds for dismissal
from my school, but may be used to alter or adjust my education settings to protect the health of myself and others with
whom I may be required to come in contact with.
I agree and consent that my electronic signature is valid and has full legal effect.
ASA Employee Signature:
Date and time:
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WEEKLY COVID-19 SYMPTOMS SCREENING ATTESTATION FORM FOR ASA (ASA College)

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Completed 3 February 2021

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