IEBC DAILY EMPLOYEE SYMPTOM SCREENING CERTIFICATION

 

I understand that, as an employee of Ironworker Employees’ Benefit Corporation, I am obligated to conduct a daily screening of symptoms for COVID-19 prior to departing for the workplace.  I understand that I may not come to work if I am exhibiting any symptoms of COVID-19, including the following symptoms:

 



In accordance with my obligation to screen myself for COVID-19 symptoms, I certify that:

         I have taken my temperature today with a working thermometer and my temperature was less than 100.4 degrees Fahrenheit.

         I am not currently exhibiting symptoms of COVID-19 or respiratory illness, including but not limited to fever or chills, cough, shortness of breath or difficulty breathing.

         If I have symptoms of a cough only, the cough is from a known, non-COVID-19 cause (e.g., asthma, allergies, COPD, etc.).

         I have not tested “positive” for COVID-19 or been diagnosed by a health care provider as having COVID-19 within the past 14 days. 

         No member of my household or individual with whom I have had close contact in the last 14 days has tested positive for COVID-19 or has been diagnosed by a health care provider with COVID-19 in the last 14 days.

         I have not been required to self-quarantine in the past 14 days under recommendation or order by a health care provider or public health official.


Select Your Manager (only select one please):









 

CERTIFICATION
The information provided above is true and accurate to the best of my knowledge.  I understand that failure to complete this certification daily, failure to accurately complete this certification to the best of my knowledge, and/or knowingly providing incorrect or false statements herein may result in Ironworker Employees’ Benefit Corporation taking appropriate action, including but not limited to sending me home until I am symptom-free and/or corrective action for violations of the certification requirements.


EMPLOYEE NAME    
SIGNATURE (If you are on a computer sign with your mouse. If you are on a mobile device you can sign with your finger)               

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DATE  (automatically populated with todays date. Change if needed)                       



Please complete this form before arriving at work.  The information provided on this form is kept confidential.
If you do not pass the COVID19 self screen test please contact your manager and do not go in to work.