Ogemaw County Employee COVID-19 Check-In Form

All Ogemaw County employees must complete the attached questionnaire each day before reporting for work.

Last Name

First Name

Date and Time of Building Entry

I certify the following statements are true: 1) I have not experienced a temperature greater than 100.4 degrees in the past 24 hours; 2) I have not experienced common COVID-19 symptoms in the past 24 hours including a cough or worsening cough, shortness of breath, chills, muscle pain and/or headache; 3) I have not been in close contact with someone who tested positive for COVID-19 in the past 14 days; 4) I have not traveled internationally in the past 14 days.

By submitting this document, you attest that, to the best of your knowledge and belief, all information reported on this form is accurate and complete. Falsification, omission, or concealment of material fact may result in disciplinary action up to and including termination of employment.

Acknowledged