This should be completed before entering a BH facility or going on site. Name* First Last Covid symptoms?*Are you experiencing any Covid-19 symptoms unrelated to known chronic conditions? Fever, Cough, Shortness of Breath, Sore Throat, Headache, Muscle Pain, Chills, Repeated Shaking with Chills, Loss of Taste or Smell. Yes No Contact with Covid patient?*Have you had known close contact to a person who is lab-confirmed to have COVID-19 and not yet received your own authorization to return to work by the Department of Health? Yes No Are you currently required to self-quarantine?*Are you currently required to self-quarantine under the NM Quarantine Order effective September 2nd? Link to ordinance. (By answering no, you are attesting that you have read and understand the restrictions) Yes No Pass Pass No Fail Fail No
