COVID-19 Self-Certification

Pre-Shift Form

How are you feeling today?

At the start of each work shift at any Wayne County Action Program, Inc. location, all employees/vounteers will complete a COVID-19 self-certification.  The certification must be completed and submitted at the start of the work shift.

After reviewing a self-certification, if Wayne CAP believes that an employee/volunteer is exhibiting COVID-19 symptoms, was exposed to COVID-19, or is unable or unwilling to self-certify, the employee will be asked to immediately leave the work premises and seek medical attention and applicable testing by their health care provider.  Employees/volunteers may not return to the workplace until cleared by a health care professional or until they are no longer experiencing symptoms for at least 10 days.

** Close contact means living in the same household as a person who has tested positive for COVID-19, caring for a person who has tested positive for COVID-19, being within six(6) feet of a person who has tested positive for COVID-19 for about 10 minutes, or coming in direct contact with secretions (eg., sharing utensils, being coughed on) from a person who has tested positive for COVID-19, while that person was symptomatic.

* I certify that the above statements are true and correct.  

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(315) 333-4155

51 Broad St, Lyons, NY 14489, USA