COVID-19 AT-HOME TEST KIT REQUEST COVID-19 At Home Test Kit Request Employee Name(Required) First Last Employee Change, Inc. Email(Required) Today's Date (Date of Request)(Required) MM slash DD slash YYYY Do you have COVID-19 Symptoms?(Required)YesNoDate Symptoms Began(Required) MM slash DD slash YYYY Were you exposed to someone who has a confirmed or sususpected case of COVID-19?(Required)ConfirmedSuspectedNo known exposureDate of Exposure(Required) MM slash DD slash YYYY Have you interacted with any clients since your exposure and/or symptom development?(Required)YesNoOver how many days did you interact with clients your exposure and/or symptom development?(Required)123Date of Client Interaction 1(Required) MM slash DD slash YYYY Date of Client Interaction 2(Required) MM slash DD slash YYYY Date of Client Interaction 3(Required) MM slash DD slash YYYY Please list the names of the clients you interacted with, followed by the appointment dates/times you did so.(Required)Example: John Smith, 2/1/22, 4pmAre there any additional details you'd like us to know?(Required)Insert n/a if none.Attestation to Submit(Required) I understand and agree to the below.1. I understand that Change, Inc. has a limited amount of COVID-19 tests and my request may be delayed or denied due to the number of tests currently available. 2. I understand that a positive COVID-19 test may result in the requirement to quarantine and see clients virtually only. 3. I will comply with Change, Inc. requirements as such and adhere to CDC/other known best practices regarding my COVID-19 status.CAPTCHA Δ
