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2. 
3. Township Employees: In accordance with Governor Murphy's Executive Order #192, please complete this short daily check list prior to the start of your workday. This form will be submitted to your supervisor. You will not be able to report to work until this form has been submitted.
5. Section 1: Symptoms
   Any of the symptoms below could indicate a COVID-19 infection and may increase the risk of spreading illness to others. Please note that this list does not include all possible symptoms, and individuals with COVID-19 may experience some, all or none of these symptoms. Please self-assess for these symptoms:
9. Section 1: Symptoms
11. Symptoms A

    1. Fever
    2. Shivers
    3. Headache
    4. Nausea or Vomiting
    5. Fatigue
    6. Chills
    7. Muscle Aches
    8. Sore Throat
    9. Diarrhea
    10. Congestion or Runny Nose
12. Symptoms B

    1. Cough
    2. Difficulty Breathing
    3. New Loss of Taste
    4. Shortness of Breath
    5. New Loss of Smell
    6. A Temperature Above 100.4 F
14. Employees who are sick (e.g., fever, vomiting, diarrhea) should not come to work. If TWO OR MORE of the fields in Symptoms A are checked off OR AT LEAST ONE field in Symptoms B is checked off, please stay home and notify your supervisor for further instructions.
16. Section 2: Close Contact/Potential Exposure
18. Please verify if within the last 14 days:

    1. You have had close contact with a person confirmed to have COVID-19 (that is within 6 feet of an infected person for at least 15 minutes over a 24-hour period).
    2. Someone in your household is diagnosed with COVID-19.
    3. You have traveled to an area of high community transmission.
    4. You were advised by a healthcare provider to quarantine related to COVID-19.
20. Sign Here
22. First Name
23. Last Name
25. Phone Number
27. Email Address
29. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
31. Electronic Signature
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

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