AMP COVID Return to Work Protocol | Adaptive Medical Partners

AMP Health, Inc. COVID Return to Work Form

Name

Have you received a positive COVID 19 test that was administered in the last 7 days? If yes, what date was that test administered? Was it a rapid test or lab based PCR test?

Have you had a fever of over 99 degrees in the last 48 hours?

Have you experienced any COVID 19 symptoms other than fever in the last 48 hours?

Have you taken any medication to control fever or other COVID 19 symptoms in the last 48 hours?

To the best of your knowledge, have you had a direct exposure (been in the same room without a mask for more than 15 minutes) with any individual who has tested positive for COVID 19 in the last 5 days? If yes, please list the date of that exposure.

To the best of your knowledge, has any member of your immediate household (roommates, spouse, children, parents) experienced COVID 19 symptoms in the last 5 days?

To the best of your knowledge, has any member of your immediate household (roommates, spouse, children, parents) received a positive COVID 19 test that was administered in the last 7 days? If yes, when was the positive test administered to that individual?

Have you received a negative COVID 19 test? When was the negative test administered? Was it a rapid test or PCR lab test?

Please type your full name as confirmation that the answers provided above are accurate and truthful to the best of your knowledge: