covid 19 attestation by Ginna McAuliffe | Sep 16, 2021 | MIT's Endicott House | 0 comments MIT COVID-19 Attestation Form Date of Visit(Required) MM slash DD slash YYYY Time(Required) Hours : Minutes AM PM AM/PM Duration of Stay(Required)Name(Required) First Last Company / Affiliation(Required)MIT ID # (if applicable)Phone / Text Number(Required)Have you been fully vaccinated for the COVID-19 virus?(Required)YesNoPlease upload proof of vaccination with dosage locations and dates.(Required)Max. file size: 50 MB.Are you experiencing fever or feeling feverish?(Required)YesNoDo you have a sore throat?(Required)YesNoNew cough (not related to chronic condition)?(Required)YesNoNew nasal congestion (not related to seasonal allergies)?(Required)YesNoMuscle aches?(Required)YesNoNew loss of smell?(Required)YesNoShortness of breath?(Required)YesNoHave you been tested and had a positive result, or have you been told by a healthcare provider that you are likely positive for COVID-19?(Required)YesNoWithin the last 14 days, have you been in close contact with anyone that you know has been diagnosed with COVID-19 or has had COVID-19 related symptoms?(Required)YesNoAre you a health care worker who has had contact with a COVID-19 positive individual as part of your work?(Required)YesNoDo you agree to wear Personal Protective Equipment (PPE) while engaging in activities on property?(Required)YesNoDo you agree to adhere to all rules and protocols of social / physical distancing while engaging in activities on property?(Required)YesNoCAPTCHA Δ
