Please enable JavaScript in your browser to complete this form.Wellness CertificateCornerstone Systems views COVID-19 as a serious health threat to its employees. Submission of this form is required before you may return to a Cornerstone office, as part of Cornerstone's Returning-to-the-Office Protocol. If for some reason you are not able to complete this form, or are uncomfortable doing so, please contact Human Resources at HR@cornerstone-systems.comNameFirstLastPosition1. Do you presently have any signs or symptoms of COVID-19, including any of the following?Persistent coughShortness of breath or difficulty breathingFeverChillsRepeated shaking with chillsMuscle painHeadacheSore throatLoss of taste or smellAny other flu-like symptoms (e.g., persistent chestpain or pressure, vomiting or diarrhea)?None2. Have you had any of the signs or symptoms of COVID-19 in the last two weeks?YesNo3. Have you been tested for COVID-19?YesNo4. In the last two weeks, have you been in close contact with someone who is experiencing the signs or symptoms of COVID-19 or who began experiencing such signs or symptoms within 48 hours of your close contact?YesNo5. In the last two weeks, have you or someone you live with been under quarantine or isolation for COVID-19?YesNo6. In the last two weeks, have you been in close contact with someone who has a confirmed diagnosis of COVID-19?YesNoIf you have any of the above described signs and/or symptoms, or answered "yes" to any of questions 1-6, you should not report to work without first speaking with your manager. Please electronically sign below to certify that your above responses are accurate to the best of your knowledge.Name *FirstMiddleLastDate *Electronic Signature *Check this box to acknowledge this as your acceptance of this agreement.NameSubmit
