Visitor COVID-19 Attestation and Questionnaire

(End date is when your job with Cureton will end. Please note if your job extends over a weekend or you leave the job for more than a day (i.e weekend) you will need to fill out a new attestation form prior to returning to the Cureton site.)

COVID-19 Attestation (Required)

attest to the following:

  1. I have not tested positive for COVID-19, nor do I have any reason to believe that I would test positive at this time;
  2. To my knowledge, I have not been exposed to other person(s) that have either tested positive for COVID-19 or have the symptoms associated with COVID-19, such as a fever or a dry cough;
  3. I have not been requested by any government entity or any medical provider to quarantine or self-isolate to prevent against possibly exposing others to COVID-19; and
  4. I have visited the following locations within the past thirty (30) days (check all boxes that apply):
    • A location outside the State of Colorado (Note: indicating this box will not automatically preclude or restrict a visitor’s access)
      • If yes, please list:
    • OR
    • I have not traveled to any of the locations listed above in the past thirty (30) days.

I, the undersigned, hereby certify that I have answered the above truthfully.