COVID-19 ATTESTATION FORM All salaried employees, Metrocenter employees, and hourly Convenience Store Managers of Mirabito must complete this form prior to reporting to work the first day of the work week. Employee ID Number:*If you are not sure what your Employee ID number is, it can be found on your badge (if you have one) and on Greenshades. In the past week, did you experience any of the following?Fever (100.4 degree fever or higher), or feeling feverish?*YesNoCough?*YesNoShortness of breath or difficulty breathing?*YesNoChills?*YesNoRepeated shaking with chills?*YesNoNew sore throat?*YesNoNew muscle aches or pains?*YesNoNew headache?*YesNoNew loss of smell or taste?*YesNoIf you answered YES to any of the questions above, what was the most recent date you had a symptom? Date Format: MM slash DD slash YYYY Have you had any known exposure to COVID 19?*YesNoHave you tested positive to COVID 19?*YesNoHave you been taken out of work by a medical provider awaiting COVID 19 test results?*YesNoHave you traveled internationally?*YesNoIf you answered YES to ANY of the questions above, please provide a contact phone number.
