COVID | Mpmalbany2

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Albany, GA

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Covid-19 Health Declaration

How are you feeling today? Please complete this declaration to agree

to allow our staff safe access to change air filter in your unit.

First Name

Last Name

Address

Email

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

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient 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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