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Self-Declaration Form For Covid-19
Please fill out the COVID-19 form
Help required for monitoring cases of Coronavirus across your organization.
Full Name:
First Name
Last Name
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This field is required.Please enter value
What department are you in:
Development
Testing
User Interface
Business Development
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Who is your manager:
Kevin
John
Mark
Larry
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Have you traveled abroad in 2020:
Yes
No
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Have you been directly exposed to someone who is suspected of having or diagnosed with COVID-19:
Yes
No
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Name of areas visited and dates of travel (Departure and Arrival):
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Please select the symptoms you're experiencing.:
High Fever
Cough
Persistent pain or pressure in chest
Body aches
Nasal congestion
Runny nose
Sore throat
Diarrhea
Difficulty breathing (e.g. unable to finish sentences because of your breathing, short of breath at rest, unable to lie down because of difficulty breathing
Others
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Please specify:
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When did you start experiencing these symptoms:
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Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Anything else you'd like to report:
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Submit
