BARRcom Computer Services

Employee Name:

Your home address:

Work Location:

Have you experienced any of the following symptoms of COVID-19 in the last 48 hours?

Fever or chills
Cough
Shortness of breath or difficulty breathing
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
None

Have you tested positive for COVID-19 in the past 10 days

Yes
No

Are you currently awaiting results from a COVID-19 test?

Yes
No

Have you been diagnosed with COVID-19 in the past 10 days?

Yes
No

Have you been told that you are suspected to have COVID-19 in the past 10 days?

Yes
No