COVID-19 Daily Health Check Self-Assessment Form

Before entering any Bressler, Amery & Ross office location, all Bressler employees and visitors, whether fully vaccinated or not, must submit the Bressler COVID-19 Daily Health Check Self-Assessment form on a daily basis.  The disclosure is required to safeguard health, safety, and limit transmission in the Bressler community.  If you aren’t feeling well, even if you are fully vaccinated, stay home, contact your physician, and take care of yourself.

Name*

Email*

Phone*

Which Bressler location are you visiting?* Birmingham Charlotte Dallas Florham Park Fort Lauderdale Houston Miami New York Washington, DC

Who are you visiting at Bressler?*

Purpose of the visit if not a Bressler employee

Check here if you are a Bressler Employee

Are You Fully Vaccinated?*

Yes

No

Recent Travel

Have you traveled within the past 14 days?*

Yes

No

What were the dates of your travel?

Where did you travel to?

Covid Contact / Exposure / Symptoms

Do you have a temperature higher than 99 degrees?*

Yes

No

Have you had contact with or cared for someone diagnosed with COVID-19 within the last 14 days?*

Yes

No

Do you have a household member who was exposed to COVID-19 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

If you have responded ‘Yes’ to any of the above Travel or Exposure/Symptoms 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.