COVID-19 Self Assessment Form

Have you or any of you close contacts tested positive for COVID in the last 14 days? Are you or any of your close contacts under waiting on results of a COVID test that was taken because of experiencing symptoms?

Do you have any one of the following new symptoms?

• Fever
• Cough
• Shortness of breath or difficulty breathing
• New loss of taste or smell
• Headache with a known COVID exposure
• Sore throat
• Muscle or body aches
• Chills or repeated shaking with chills
• Congestion or runny nose
• Nausea or vomiting
• Diarrhea

By completing this questionnaire, I affirm the answers I have provided above are accurate. In addition, I agree to follow required safety precautions mandated by CoxHealth. At a minimum, those include wearing a mask that covers my nose and mouth at all times while on any CoxHealth campus, unless I am alone in a private office safely distanced from others. I also understand that I may be subject to disciplinary action, up to and including termination of employment, if I fail to follow the safety precautions mandated by CoxHealth.