Checklist and Attestation for HCP Return to Work Waiver

Facility Information
Facility Type
Facility Point of Contact
Is the Healthcare entity correctly furloughing staff exposed to COVID-19?
Has the healthcare entity implemented staffing mitigation strategies?

(consult CDC’s Strategies to Mitigate Healthcare Personnel Staffing Shortages for suggestions)

Upload Paper form with CEO Signature

Required form can be found on page 5 of the guidance document titled:
Revised Protocols for Personnel in Healthcare and Other Direct Care Settings to Return to Work Following COVID-19 Exposure

Upload requirements