| TO: | All Employees |
| FROM: | Human Resources |
| DATE: | |
| RE: | Protocol For Returning to Work: Employees Who Have Tested Positive For the Coronavirus OR Who Have Or May Have Been Exposed To The Coronavirus |
As the global situation with the Coronavirus (“COVID-19”) continues to move at an unprecedented pace, [Company] continues to monitor the situation closely to ensure the safety of our team members. [Company] remains ready to take additional action as part of its business continuity plan to protect the safety, health, and well-being of our employees.
For all employees returning to non-remote work at [Company] who have or may have been exposed to COVID-19, employees must fill out and sign the attached questionnaire prior to re-entering the workplace. Employees who “have or may have been exposed to COVID-19” include any employee who has:
- tested positive for COVID-19, experienced fever, chills, cough, shortness of breath, sore throat, and/or exhibited any other flu-like symptoms or respiratory issues in the last fourteen (14) days;
- who tested positive for COVID-19, experienced fever, chills, cough, shortness of breath, sore throat, and/or exhibited any other flu-like symptoms or respiratory issues in the last fourteen (14) days;
- to China, Hong Kong, Iran, any European country, Japan, South Korea, returned from a cruise, or travelled to any other high risk region (as defined by the CDC’s travel alert) in the last fourteen (14) days or had close contact with some who has travelled to any such high risk region or returned from a cruise in the last fourteen (14) days; and/or
- due to potential exposure to COVID-19.
[Company] has and continues to implement additional cleaning regimens for high-touch surfaces in addition to our regular cleaning schedule. Per the CDC’s recommendations, employees are strongly encouraged to leverage [Company]’s technology to limit in-person meetings, when reasonable. [Company] recommends that team members maintain a distance of six feet when coming into contact with one another.
If
you have any questions or concerns, please contact your manager or Human
Resources. We
thank you in advance for your cooperation as we take these steps to ensure the
safety, health, and well-being of our team.
QUESTIONNAIRE
Please respond by checking any box applicable to you and sign below:
- , have you recovered from COVID-19 and been medically released to return back to work from a licensed medical professional? If so, please check this box and sign and return with your note from your medical provider.
- , have you completed
a 14-day self-quarantine due to:
- to China, Hong Kong, Iran, any European country, Japan, South Korea, returned from a cruise, or travelled to any other high risk region (as defined by the CDC’s travel alert), or having had close contact with some who has travelled to any such high risk regions or returned from a cruise, and finished the 14-day quarantine period without developing symptoms;
- who tested positive for COVID-19 and/or a person who had fever, chills, cough, shortness of breath, sore throat, or exhibited any other flu-like symptoms or respiratory issues, and finished the 14-day quarantine period without developing symptoms;
- under local health guidelines, and finished the 14-day quarantine period without developing symptoms;
- fever, chills, cough, shortness of breath, sore throat, or having exhibited any other flu-like symptoms or respiratory issues, and have not demonstrated symptoms for 72 hours after completion of the 14-day quarantine period.
In all cases in which you checked a box above, please also confirm last date worked on-site and last date of symptoms:
Last date worked on-site: _______________________
Last date of symptoms: _________________________
Please sign this document after checking the appropriate box above and submit the document to Human Resources, along with, if applicable, any return to work note from your medical provider.
By signing below, you certify that your answers to the questionnaire are true to the best of your knowledge. You also certify that you will inform your manager or Human Resources Business Partner immediately if your answer to any of the questions above changes.
Employee Name (printed): __________________ Employee Signature: __________________