Employee Return-to-Work Survey Name First Last Health and SafetyDo you have any of these symptoms: fever, aches, cough, shortness of breath, chills, muscle pain, headache, sore throat, new loss of smell?* Yes No Have you come in contact with anyone diagnosed with COVID-19?* Yes No Are you currently waiting for the results of a COVID-19 test?* Yes No Have you traveled outside Maryland over the last 14 days?* Yes No PreparednessHas your availability changed since you last worked with Baltimore Home Cleaning?* Yes No Please explain why your availability has changed:*What is your new work availability for Monday through Saturday?*How do you feel about returning to work with Baltimore Home Cleaning?*On a scale of 1-5, how concerned are you about the COVID-19 outbreak impacting your health or safety in the workplace?*1 = Not at all concerned2345 = Extremely concernedAcknowledgements* I understand my responsibility to not come to work if I have symptoms of COVID-19 or have recently come into contact with someone who has COVID-19. I understand my responsibility to comply with Baltimore Home Cleaning’s health and sanitation standards.
