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COVID-19 Self-Certification

Pre-Shift Form

How are you feeling today?

At the start of each work shift at any Wayne County Action Program, Inc. location, all employees/vounteers will complete a COVID-19 self-certification.  The certification must be completed and submitted at the start of the work shift.

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After reviewing a self-certification, if Wayne CAP believes that an employee/volunteer is exhibiting COVID-19 symptoms, was exposed to COVID-19, or is unable or unwilling to self-certify, the employee will be asked to immediately leave the work premises and seek medical attention and applicable testing by their health care provider.  Employees/volunteers may not return to the workplace until cleared by a health care professional or until they are no longer experiencing symptoms for at least 10 days.

** Close contact means living in the same household as a person who has tested positive for COVID-19, caring for a person who has tested positive for COVID-19, being within six(6) feet of a person who has tested positive for COVID-19 for about 10 minutes, or coming in direct contact with secretions (eg., sharing utensils, being coughed on) from a person who has tested positive for COVID-19, while that person was symptomatic.

* I certify that the above statements are true and correct.  

Thanks for submitting!

We're so thankful for our Sponsors!

(315) 333-4155

51 Broad St, Lyons, NY 14489, USA

This website is supported by a Community Services Block Grant within the Administration for Children and Families, a division of the U.S. Department of Health and Human Services.  Neither the Administration for Children and Families nor any of its components operate, control, are responsible for, or necessarily endorse this website (including, without limitation, its content, technical infrastructure, and policies, and any services or tools provided).  The opinions, findings, conclusions, and recommendations expressed are those of the author(s) and do not necessarily reflect the views of the Administration for Children and Families.

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