Employee Screening Database | Rustic Spud

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Rustic Spud Staff Pre-Shift

Covid-19 Health Declaration

How are you feeling today before you start your shift?

First Name

Last Name

Email

Temperature

My body temperature is lower than 98.6°F/ 37.5°C

I delcare that I am not displaying any of the following symptoms: fever, dry cough, tiredness, aches and pains, sore throat, diarrhoea, conjunctivitis, headache, loss of taste or smell, or rash on skin.

I have not been in close contact with a Covid-19 patient or any idividual under investigation for COVID-19 in the last 14 days.

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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