COVID-19 Employee Self-Certification to Return to Work

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I, _______________________, attest to the following:

I have had no fever for at least 24 hours without taking medication to reduce fever during that time.

Date of last fever of 100.4 degrees or higher: _____________________

 

My symptoms have improved.

Date symptoms began improving: ______________ (write N/A if no symptoms present)


At least ten days have passed since my fever and/or respiratory symptoms began.

Date fever and/or symptoms began: _____________________

 

Employee name: ______________________________________________

Employee signature: ___________________________________________

Today's date: _________________________________________________

Date returned to work: _________________________________________


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The following is provided for an employee's personal use to document his or her symptoms and recovery. This page should not be provided to the employer but kept for the employee's personal records.

Date symptoms began: _________________

Date of last fever of 100.4 degrees or higher: ___________________

Date symptoms began improving: ___________________

Date
​Temperature
​Other symptoms? (Y/N)
​Other symptoms or notes




























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