Helping Hand

Self-Certification and Verification Form for Staff, Visitors, and Volunteers

COVID-19 SELF-ASSESSMENT CHECKLIST

1. Have you received a confirmed diagnosis for coronavirus (COVID-19) by a coronavirus (COVID-19) test or from a diagnosis by a health care professional in the past 14 days?

YES
NO

2. Have you had close contact with someone diagnosed with COVID-19 within the last 14 days? The CDC considers close contact to mean the individual was within 6 feet of the person who tested positive for COVID-19 or is suspected of having COVID-19 infection for more than 15 minutes.

YES
NO

3. Have you experienced any cold or flu-like symptoms in the last 14 days to include:

Select below *

Temperature of 99.5 (or greater) degrees Fahrenheit
New Cough;
New onset of moderate to severe headache;
New congestion or runny nose;
New loss of taste or smell;
Shortness of breath;
Sore throat;
Nausea and/or Vomiting;
Diarrhea;
Abdominal pain from a unknown source;
Fatigue from an unknown cause;
Muscle and body aches;
Any other COVID-10 symptoms identified by the CDC or IDPH
None of the above

4. I agree to properly wear a mask, including over my mouth and nose, at all times while on Helping Hand property.

By typing my name below, I hereby acknowledge and agree to the terms above, and affirm that the information provided is truthful to the best of my knowledge.

Today's Date:

First Name:

Last Name:

Phone:

Email:

IF THE VOLUNTEER IS 18 YEARS OLD OR YOUNGER A PARENT OR GUARDIAN MUST REVIEW THIS FORM AND TYPE THEIR NAME BELOW.

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