Certification of Well-Being for COVID-19

To all Staff and Visitors spending more than 10 minutes on site:

Welcome to Lazarus House!

Thank you for complying with our COVID-19 re-opening policies and procedures.

When you reach the building’s Monitoring Station please complete the following form to certify your well-being and to provide us with the ability for contact tracing if needed.

Certification of Well-Being for COVID-19 Reopening

Date:*
Time of Arrival:*
Visitor or Staff?*
I will be working at the:
If you are a Visitor, who are you meeting with?*
Visitor's cell phone:*
Name*
First Last
Temperature
Certification*
My signature below certifies that I have no signs of illness such as fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea.
Certification*
I have not knowingly been in close contact with anyone diagnosed with Covid-19 in the last 14 days.
Please Type Your Name*
First Last
If your temperature is above 99.5 F, please take care of yourself and go home.
Phone
This field is for validation purposes and should be left unchanged.

Certification of Well-Being for COVID-19 Reopening

If your temperature is above 99.5 F, please take care of yourself and go home.