Return to Work Following Illness Certification Form

    Your Name - First and Last (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).

    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).

    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.

    4) At least 7 days have passed since my COVID-19 symptoms first appeared.
    Date symptoms first appeared:

    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.

    6)

    7) Date returning to work:

    Please attach Doctor's note: