EMPLOYEE RETURNING TO ON-S - Polar Semiconductor, Inc - …



Novel Coronavirus 2019 (COVID-19) Employee Return To Work AffidavitTesting Type Note: Polar will not accept test results that are self-administered and self-reported.This affidavit PLUS any requested documentation must be returned together to covid19@ Only checkmark boxes in the one below category that best applies to your COVID situation. Please ensure you are completing the correct area of the form – there is a separate section starting on page two for employees who already had a confirmed case of COVID-19 in the past three months or are up to date on COVID-19 vaccinations*. *UP TO DATE: Boosted OR Completed primary series of Pfizer or Moderna within the last six months OR Completed the primary series of J&J within the last two months.Please also ensure that you provide name, date, etc. as requested directly below.Failure to comply with this process and/or provide complete information in a proper and timely manner is a procedure violation and actionable under the Procedure Violation Policy.Employee Name: Click or tap here to enter text. Employee Number: Click or tap here to enter text.Date: Click or tap here to enter text.Manager: Click or tap here to enter text.Preferred E-mail: Click or tap here to enter text.Preferred Phone #: Click or tap here to enter text.------------------------------------------------------------------------------------------------------------------------------------------------------------------------- EMPLOYEE TESTED POSITIVE FOR COVID-19 ?? I attest that it has been at least five days since my COVID symptoms first appeared (or five days since the testing date if you have no symptoms) AND at least 24 hours since resolution of my last fever without the use of fever reducing medicine AND I’ve had improvement in symptoms. Loss of taste and smell may persist for weeks or months after recovery and need not delay the end of isolation or return to work. ? Important Note: You may need to stay home longer than five days if 1) your symptoms are not improving or become worse, 2) if you have conditions that weaken your immune system, or 3) if you have been in the hospital. Talk to your healthcare provider for instructions in this situation. If you will be off longer than the standard five days you should request a doctor’s note stating when you can safely return to work and provide that note to covid19@ . Note: Mask for days 6-10.EMPLOYEE HAD SYMPTOMS BUT EMPLOYEE TESTED NEGATIVE FOR COVID-19 ?? I attest that I have been symptom free for 24 hours without the use of pain or fever reducing medications. PLUS ?? Attached is documentation showing my negative COVID-19 test result. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------HOUSEHOLD MEMBER TESTED POSITIVE FOR COVID-19 ?? I attest that it has been five days since my household member completed their isolation period (usually five days from the day their symptoms started, or if they did not have symptoms, five days from the day they got tested). PLUS?? Attached is documentation showing my negative COVID-19 test which was taken at least five days following completion of household member’s isolation. Note: Mask for days 6-10. NON-HOUSEHOLD MEMBER / IDENTIFIED CLOSE CONTACT INDIVIDUAL TESTED POSITIVE FOR COVID-19 ?? I attest that it has been five days since my last possible exposure date and I have no COVID symptoms PLUS?? Attached is documentation showing my negative COVID-19 test which was taken at least five days following the date of the last possible exposure. Note: Mask for days 6-10.HOUSEHOLD MEMBER OR CLOSE CONTACT INDIVIDUAL HAD COVID-19 SYMPTOMS BUT TESTED NEGATIVE FOR COVID-19?? I attest I have no COVID symptoms PLUS?? Attached is documentation showing my family member’s negative COVID-19 test result. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------EMPLOYEE – RECENT INTERNATIONAL TRAVEL OR RECENT CRUISE?? I attest that it has been 3-5 days since my last possible exposure date and I have no COVID symptoms PLUS?? Attached is documentation showing my negative COVID-19 test which was taken at least 3-5 days following the date of the last possible international travel or cruise exposure. Or ?? I attest that it has been five days since my last possible exposure date and I have no COVID symptoms. (no test)-------------------------------------------------------------------------------------------------------------------------------------------------------------------------I OR MY IMMEDIATE FAMILY MEMBER IS/WAS HIGH RISK PER CDC?? I attest that I, or my physician deems, I can now return to work. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------COVID SITUATION THAT IS NOT ADDRESSED ON THIS FORM?? Please contact covid19@ regarding what is needed for your return to work. Return the requested items with this form. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------THE BELOW FOUR CATEGORIES ARE FOR EMPLOYEES THAT ALREADY HAD A CONFIRMED CASE OF COVID-19 IN THE PAST THREE MONTHS OR THE EMPLOYEE IS UP TO DATE ON COVID-19 VACCINATIONS UP TO DATE:Boosted -OR-Completed the primary series of Pfizer or Moderna vaccine within the last six months -OR-Completed the primary series of J&J vaccine within the last two monthsEMPLOYEE TESTED POSITIVE FOR COVID-19 ?? I attest that it has been at least five days since my COVID symptoms first appeared (or five days since the testing date if you have no symptoms) AND at least 24 hours since resolution of my last fever without the use of fever reducing medicine AND I’ve had improvement in symptoms. Loss of taste and smell may persist for weeks or months after recovery and need not delay the end of isolation or return to work.? Important note: You may need to stay home longer than five days if 1) your symptoms are not improving or become worse, 2) if you have conditions that weaken your immune system, or 3) if you have been in the hospital. Talk to your healthcare provider for instructions in this situation. If you will be off longer than the standard five days you should request a doctor’s note stating when you can safely return to work and provide that note to covid19@ . Note: Mask for days 6-10.EMPLOYEE HAS ALREADY HAD OWN COVID-19 DIAGNOSIS/RECOVERY WITHIN THE LAST THREE MONTHS OR THE EMPLOYEE IS UP TO DATE ON COVID-19 VACCINATIONS AND EMPLOYEE HAD POSSIBLE/CONFIRMED COVID-19 EXPOSURE (via family member, close contact) or WENT ON A CRUISE or TRAVELLED INTERNATIONALLY AND EMPLOYEE HAS NO SYMPTOMS. ?? I attest I have no COVID symptoms PLUS?? I attest that I was already diagnosed previously with COVID-19 and recovered within the last three months. That COVID-19 test was taken on Click or tap here to enter text. (provide date). OR I attest I am up to date on COVID-19 vaccinations. Get tested for COVID on day five after the last possible exposure. If you test positive, see this section of the screening form for new instructions: EMPLOYEE TESTED POSITIVE FOR COVID-19. If the test is negative, no follow up is needed with Polar. If you had a confirmed close contact COVID exposure, wear a mask indoors in public for 10 days following exposure or until you receive your negative test result.EMPLOYEE HAS ALREADY HAD OWN COVID-19 DIAGNOSIS/RECOVERY WITHIN THE LAST THREE MONTHS OR THE EMPLOYEE IS UP TO DATE ON COVID-19 VACCINATIONS AND EMPLOYEE HAD POSSIBLE/CONFIRMED COVID-19 EXPOSURE (via family member, close contact) or WENT ON A CRUISE or TRAVELLED INTERNATIONALLY AND EMPLOYEE EXPERIENCED COVID symptoms RELATED TO THIS COVID-19 EXPOSURE OR CRUISE/TRAVEL Note: If the employee has symptoms and also tests positive for COVID-19, please use the return to work criteria toward the top of this page for EMPLOYEE TESTED POSITIVE FOR COVID-19.?? I attest that I have been symptom free for 24 hours without the use of pain or fever reducing medications. PLUS ?? I attest that I was already diagnosed previously with COVID-19 and recovered within the last three months. That COVID-19 test was taken on Click or tap here to enter text. (provide date). OR I attest I am up to date on COVID-19 vaccinations. PLUS?? Attached is a doctor’s note stating that I can return to work and/or my recent negative COVID-19 test result (related to these current symptoms).EMPLOYEE HAS ALREADY HAD OWN COVID-19 DIAGNOSIS/RECOVERY WITHIN THE LAST THREE MONTHS OR THE EMPLOYEE IS UP TO DATE ON COVID-19 VACCINATIONS AND EMPLOYEE EXPERIENCED COVID SYMPTOMS AGAIN Note: If the employee has symptoms and also tests positive for COVID-19, please use the return to work criteria toward the top of this page for EMPLOYEE TESTED POSITIVE FOR COVID-19.?? I attest that I have been symptom free for 24 hours without the use of pain or fever reducing medications. PLUS?? I attest that I was already diagnosed previously with COVID-19 and recovered within the last three months. That COVID-19 test was taken on Click or tap here to enter text. (provide date). OR I attest I am up to date on COVID-19 vaccinations. PLUS?? Attached is a doctor’s note stating that I can return to work and/or my recent negative COVID-19 test result (related to these current symptoms).1/18/22 ................
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