Lifespan Employee Health Screening Form Please fill out the form below to determine whether you should come to work. First Name Last Name Lifespan Email Address Department Lifespan Hospital/Affiliate Select oneRhode Island HospitalHasbro Childrens HospitalThe Miriam HospitalBradley HospitalNewport HospitalGateway HealthcareLifespan Physician GroupLifespan School SolutionsLifespan Corporate Services Attestation of Health Please answer the question below related to your symptoms and current quarantine status. In the past 24 hours, have you experienced any of the following symptoms: Fever Chills Cough Sore Throat Diarrhea Shortness of Breath Body Aches Reduced Sense of Taste or Smell OR Have you been told to quarantine yourself by any public health authority in the past 14 days? symptoms - Select -Yes, I have experienced one or more of these symptoms in the past 24 hours.No, I have not experienced any of these symptoms.I have been advised to quarantine by a public health authority in the past 14 days Please indicate which symptoms you have experienced: FeverChillsCoughDiarrheaShortness of breathBody AchesSore ThroatLoss of SmellReduced Taste CAPTCHA Leave this field blank
