Health - The Bonura Hospitality Group

Employee Name*

First Last

Select Your Venue*

COVID-19 Assessment Form

Complete Part One, answering the “Yes” or “No” questions by checking the applicable box for each question.

Question One*

Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19?

Yes
No

Question Two*

Have you tested positive for COVID-19 in the past 14 days?

Yes
No

Question Three*

Have you experienced any symptoms of COVID-19 in the past 14 days?

Yes
No

FInal Step

By completing this Form, you are certifying your responses are true and correct. You understand that if you are unable or unwilling to complete the Form, you will not be able to work on premises. If you believe circumstances permit you to return to work on premises without completing the Form, contact your site safety monitor.

Please confirm your answers*

I confirm all of my responses to the previous questions are true for me on this date.

Name

This field is for validation purposes and should be left unchanged.

COVID-19 Self-Assessment Form

COVID-19 Assessment Form

FInal Step