Workr From Home Form Name* First Last Do you have any symptoms (fever, consistent new cough)?* Yes No Have you had contact with anyone who does recently?* Yes No Do you have underlying health concerns?* Yes No Do you live with other people that are vulnerable (>60 years old and/or have underlying health conditions)?* Yes No Do you have a computer or laptop at home?* Yes No Did you successfully test the logins at home?* Yes No Does your mobile phone hold a consistent signal at home?* Yes No Do you have a land line?* Yes No Are there any reasons why you think you should or shouldn’t stay home?