COVID 19 Survey HR Form

Your Full Name*

Personal Email*

Personal Phone Number*

I AM vaccinated WITH a booster within the last 6 months. Vaccine AND Booster.
I AM vaccinated WITHOUT a booster (2 shots of Moderna, or 2 shots of Pfizer or 1 shot of J&J) .
I AM NOT vaccinated.

I have had COVID (tested positive) in the last 90 days (3 months).
If prior COVID, I AM symptomatic
If prior COVID, I AM NOT symptomatic

I was directly exposed to COVID. Someone I was in direct contact with tested positive.*
YesNo
Date of Exposure:

I was possibly exposed to COVID. I was in close contact with someone who is probable for COVID.*
YesNo
Date of Exposure:

I AM experiencing COVID symptoms.
Describe possible COVID related symptoms:

I have taken a COVID test. I AM waiting results or I am Scheduled for a test.
Test Date:

Office Location*:

Close contacts if you believe you exposed someone at your office or a clients:

General Comments:

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