Office of the Vermont Attorney General

TJ Donovan, Vermont Attorney General

2020 Return to Work Screening Survey

Potential symptoms of COVID-19 include fever, shortness of breath, cough, sore throat, chills, muscle pain, and recent loss of taste or smell. If you have any of these symptoms, unless they are a result of a condition known to you that is unrelated to COVID-19, you may not enter any AGO facility. If you do not have any of these symptoms, please complete and electronically sign this form before going into the office.

Name *

Who is your Supervisor? *

What Location do you plan on entering?

I have not felt feverish within the last 24 hours, have taken my temperature today with a thermometer, and do not have a temperature of 100.4°F or higher. *

Agree

I have not had any of the following symptoms within the past 24 hours, unless they are a result of a condition known to me that is unrelated to COVID-19: cough, shortness of breath or difficulty breathing, chills, muscle pain, sore throat, or recent loss of taste or smell. *

Agree

I have not traveled out of state within the last 14 days for nonessential business, or have reviewed the current travel quarantine guidelines issued by the Vermont Department of Health and can enter an AGO facility consistent with the guidelines. *

Agree

I verify by entering my name that the above information is true and accurate *

109 State St
Montpelier, VT 05609

(802) 828-3171

Vermont’s lobbyist registration and disclosure law applies to certain communications with and activities directed at the Attorney General. Prior to any interactions with the Office of the Vermont Attorney General, you are advised to review Title 2, Sections 261-268 of the Vermont Statutes Annotated, as well as the Vermont Secretary of State’s most recent guide to compliance, available at https://www.sec.state.vt.us/elections/lobbying.aspx.