COVID-19 Return to Work Form from OXIO Employee Form

Employee Name

Manager Name

Workplace Address

Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, flu like symptoms or loss or change to your sense of smell or taste now or in past 14 days?

yes no

Have you been in close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days? (i.e. relative, neighbor, school, etc.)?

yes no

Have you or anyone in your household traveled outside the state or country in the last 30-days?

yes no

Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?

yes no

Have you been advised by a doctor to self-isolate at this time?

yes no

If yes, have you been cleared by a doctor to return to work?

yes no

Please provide any details below of any other circumstances relating to COVID-19, not included in the above, which may need to be considered to allow your safe return to work.

Employee Signature

Title

Date

This consent is specifically to permit an electronic signature as to OXIO Health, Inc. (OXIO) in lieu of handwritten signatures on any one or more of the Documents. OXIO consents to accept such signatures as true, correct and binding signatures of any Consenting Party and to enter into the Post COVID-19 Reopening Plan in reliance thereon. By clicking the checkbox you agree that your electronic signature will be enforceable as and to the full extent of a hand-written signature as an original for enforcement/enforceability of the Documents containing the electronic signature(s), whether in court (state or federal), arbitration or otherwise. You will not raise any defenses or invoke regulatory or statutory claims attempting to invalidate the enforceability of the Documents to which the electronic signature is affixed. OXIO Health, Inc. shall not be liable in any manner or to any extent for any direct, indirect, special, incidental or consequential damages, losses or expenses arising out of the use of this template.

COVID-19 Return to Work Form

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