Employee Health Declaration HR
EMPLOYEE HEALTH DECLARATION
Your health and safety are our top priorities. Please complete this Employee Health Declaration to help us maintain a healthy workplace environment and prevent the spread of illness among our team.
EMPLOYEE INFORMATION
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Full Name: |
[Your Name] |
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Employee ID: |
50-980 |
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Department: |
Human Resource |
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Date of Submission: |
June 10, 2050 |
HEALTH INFORMATION
COVID-19 Related Questions:
Have you traveled to a high-risk area within the last 14 days?
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Yes
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No
Have you been in close contact with someone who tested positive for COVID-19 in the last 14 days?
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Yes
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No
Do you currently have any of the following symptoms: fever, cough, shortness of breath, loss of taste or smell?
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Yes
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No
If you answered "Yes" to any of the above questions, please provide details:
General Health Questions:
Do you have any medical condition that may impact your ability to perform your job safely and effectively?
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Yes
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No
If you answered "Yes," please provide details:
Vaccination Status:
Have you been fully vaccinated against COVID-19?
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Yes
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No
If "Yes," please provide the date of your final dose: ________________
If "No," do you intend to get vaccinated?
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Yes
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No
Wellness Programs:
Are you interested in participating in our workplace wellness programs?
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Yes
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No
If "Yes," please specify your areas of interest (e.g., fitness, stress management, nutrition):
Employee Signature:
__________________________
