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/were you:Have you had a fever?*YesNoTravel via a plane?*YesNoTravel to a State identified as a State with significant community spread of COVID-19?*To view the current list of restricted states, please visit: NYS Travel Restrictions List YesNoI have visited a nursing home, hospital, or correctional facility.*YesNoTested positive or are awaiting results from a recent test for COVID19?*YesNoReside with anyone who tested positive to COVID19?*YesNoExposed to anyone who tested positive to COVID19?*YesNoPlaced in quarantine by a medical provider?*YesNoPlaced in quarantine by the Department of Health?*YesNoOn the date of this Questionnaire:In the last seven days have you had a fever, cough, shortness of breath, loss of taste or smell or other flu like symptoms?*YesNoIf you answered yes to the question above, what was the date you last had a fever, cough or shortness of breath? Date Format: MM slash DD slash YYYY If you answered yes...If you answered yes to ANY of the questions above, please provide a contact phone number.
