Return to Work Following Illness Certification Form

Your Name - First and Last (required)

Your Work Email (required)

Please put a check next to each statement indicating agreement (required)

1) It has been at least 3-days (72 hours) since I have had a fever (100.4° F or higher) without the use of fever-reducing or other symptom-altering medicines (e.g., cough suppressants).
Yes, this is correct.

2) I have not exhibited respiratory symptoms related to COVID-19 (coughing or shortness of breath) in the past 72 hours without the use of symptom-altering medicines (e.g., cough suppressants).
Yes, this is correct.

3) I have not exhibited any other symptoms (e.g., loss of taste or smell, gastrointestinal problems, such as nausea, diarrhea, and vomiting) in the past 72 hours without the use of symptom-altering medicines.
Yes, this is correct.

4) At least 7 days have passed since my COVID-19 symptoms first appeared.
Date symptoms first appeared:
Yes, this is correct.

5) I have not been in close contact with anyone who has exhibited any COVID-19 symptoms or tested positive for COVID-19 in the past 7 days. *Close contact means living in the same household or being within six feet of a person for 15-minutes.
Yes, this is correct.

6) Date(s) absent from work: (required)

7) Date returning to work:

Please attach Doctor's note:

Additional Information:

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