COVID-19 Daily Health Check Self-Assessment Form

Before entering any Bressler, Amery & Ross office location, all Bressler employees and visitors must complete the Bressler COVID-19 Daily Health Check Self-Assessment form on a daily basis. The disclosure of exposure or illness is required to safeguard the health and safety, and limit transmission in the Bressler community. If you have one or more symptom(s) that may be related to COVID-19, please stay home, call your physician’s office, and take care of yourself.

Name*

Email*

Phone*

Office Visiting/Bressler Hosts* Birmingham Charlotte Dallas Florham Park Fort Lauderdale Houston Miami New York Washington, DC

Name of Bressler Host/Who are You Visiting*

Check here if you are a Bressler Employee

Purpose of the Visit (If not a Bressler employee)

Do you have a temperature higher than 99 degrees?*

Yes

No

Recent Travel

Have you or someone you have been in contact with traveled internationally, within the US, or been on a cruise ship within the past 14 days?*

Yes

No

If yes, what date did you leave for your travel?

If yes, what states or countries did you visit?

Covid Contact / Exposure / Symptoms

Have you had contact with or cared for someone diagnosed with 2019 Novel Coronavirus within the last 14 days?*

Yes

No

Have you experienced any cold or flu-like symptoms within the last 14 days (including fever, cough, sore throat, respiratory illness, or difficulty breathing?*

Yes

No

Do you have a household member who is a healthcare professional and exposed to 2019 Novel Coronavirus?*

Yes

No

If you have responded 'Yes' to any of the above questions please contact Bressler's HR Department at selfevaluation@bressler.com prior to your arrival at the office.

Enter code shown below*

X Code

* Indicates a required field.