COVID-19 Wellness Survey

1. Employee Name:
2. Employee Personal Phone Number:
3. Have you experienced any COVID-19 symptoms?
Yes
No
4. If applicable, list the symptoms:
5. If applicable, how long have you had the symptoms:
6. Have you been exposed to someone who is experiencing symptoms of COVID-19 and/or who has been confirmed positive with COVID-19?
Yes
No
7. Comments:
8. List anything you think we should know:
9. List any Saber Employee you have been in close contact with (closer than 6 ft):
Were you wearing a mask?
 
 
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