NBHealthCert – Central Jersey Legal Services, Inc.

Central Jersey Legal Services Health Certification

Please fill out the questions below upon each visit to the office.

IF YOU ARE UNABLE TO COMPLETE THE FORM BELOW: Please contact Sylvia and your director.

Name *

Date *

Phone

Office *New BrunswickPerth AmboyElizabethTrentonWhich office are you visiting?

Have you received the COVID19 vaccine? *Yes I am fully vaccinatedI am not fully vaccinated

I hereby certify that my COVID-19 vaccination was completed more than 14 days ago. *YES my covid vaccination was completed more than 14 days ago.

I hereby certify that I have taken my temperature when I came into the office and it is under 100 degrees. *YES, my temperature was taken upon entering the office and it is under 100 degrees

Have you developed any of the following symptoms in the last 7 days: Cough, shortness of breath or difficulty breathing, fever, chills, sore throat, new loss of taste or smell, gastrointestinal symptoms like nausea, vomiting, or diarrhea, chest pain, fatigue, muscle or body aches, headache, congestion or runny nose. *NO, I have not experienced any of the listed symptoms in the last 7 days.YES, I have experienced some of the listed symptoms in the last 7 days.

Have you received a negative COVID-19 test result before returning to the office? *I have received a negative COVID-19 test result after experiencing these symptoms.

Have you traveled within the continental US (other than NY, NJ, OR PA) in the last 5 days? *NO, I have not traveled within the continental US (other than NY, NJ, OR PA) in the last 5 days.YES, I HAVE traveled within the continental US (other than NY, NJ, OR PA) in the last 5 days.

Have you received a negative COVID-19 PCR test result before returning to the office? *Yes, I have received a negative COVID-19 PCR test result before returning to the office.

Have you traveled internationally or to Hawaii, Alaska or US territories in the last 5 days?NO, I have not traveled internationally or to Hawaii, Alaska or US territories in the last 5 days.YES, I HAVE traveled internationally or to Hawaii, Alaska or US territories in the last 5 days.

Have you worked from home for 5 days after travel and received a negative COVID19 PCR test?Yes, I have worked from home for 5 days after travel, and I have received a negative COVID19 PCR test.

Have you been exposed to anyone who has COVID-19 in the last 5 days? *NO, I have NOT been exposed to COVID-19 in the last 5 days.YES, I HAVE been exposed to COVID-19 in the last 5 days.

Have you worked from home for 5 days after exposure AND received a negative COVID19 PCR test? *YES, I have worked from home for 5 days after exposure AND received a negative COVID19 PCR test.

Have you experienced secondhand exposure to COVID19 in the last 5 days?NO, I have not experienced secondhand exposure to COVID19 in the last 5 days.YES, I have experienced secondhand exposure to COVID19 in the last 5 days.

Please contact Sylvia and your director for further instruction.

Contact Information

Union : 908-354-4340

Mercer: 609-695-6249

Middlesex: 732-249-7600