STARLITE | Health Declaration

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Mandatory Health Declaration

BY SUBMITTING THIS FORM, YOU ARE ATTESTING THAT YOUR RESPONSES ARE ACCURATE AND TRUTHFUL. SUBMITTING FALSE OR MISLEADING INFORMATION ON THIS FORM WILL BE GROUNDS FOR DISCIPLINARY ACTION, UP TO AND INCLUDING TERMINATION OF EMPLOYMENT AND LEGAL IMPLICATIONS.

Contact Information

First name

Last name

Company

EmailWhere you will receive a confirmation email.

Date Submitted

Please answer the following required questions:

Have you had any symptoms of COVID-19 (chills, congestion or runny nose, cough diarrhea, fatigue, fever, headache, muscle or body ache, nausea or vomiting, new loss of taste or smell, shortness of breath or difficulty breathing, or sore throat) within the last 72 hours?

YesNo

Are you under any order to quarantine from a healthcare professional due to exposure or symptoms of COVID-19?

YesNo

Have you had any close contact with an individual diagnosed with COVID-19? Close contact includes living in the same household as a person who has tested positive for COVID-19, or caring for a person who has tested positive for COVID-19, or being within 6 feet of a person who has tested positive for COVID-19.

YesNo

All travelers are encouraged to follow travel recommendations from the CDC. International travelers must also follow federal requirement. The CDC recommends delaying all domestic and international travel until you are fully vaccinated.

TRAVEL INFORMATION:

(02.03.2022)