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Covid-19 Self-Assessment Form

  1. Township of Jackson 1844

  2. 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.

  3. 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:

  4. Section 1: Symptoms

  5. Symptoms A

  6. Symptoms B

  7. 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.

  8. Section 2: Close Contact/Potential Exposure

  9. Please verify if within the last 14 days:

  10. Sign Here

  11. 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.

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