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Jefferson Township

mbeekman@jeffersontownship.net

1033 Weldon Rd, Lake Hopatcong, NJ, 07849, US

973-208-6109

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Employee Health Screening Form

Full Name

Have you had a temperature of 100.4 or higher within the past 3 days? If so, please call Administration:

Please indicate if you have had the following symptoms within the last 14 days:

Over the past 14 days have you been in close contact with any person who has tested positive for COVID-19?

Over the past 14 days have you been in close contact with any person who has had symptoms of COVID-19 without being tested?

Have you traveled out of the state over the past 14 days, or do you have plans to do so?