Checklist and Attestation for HCP Return to Work Waiver

  • 1 Current Applicant Information
  • 2 Checklist
  • 3 Attestation Upload
  • 4 Complete

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Revised Guidance Published March 10, 2021

Revised guidance can be found at the link below. Please note that the revised guidance also includes revisions to the Checklist and Attestation Form. 

Update to Interim Health Advisory: Revised Protocols for Personnel in Healthcare and Other Direct Care Settings to Return to Work Following COVID-19 Exposure - Including Quarantine and Furlough Requirement for Different Healthcare Settings

Facility Type
Facility Information

NOTE: A separate application must be submitted for each facility/location seeking a waiver. Applications requesting a waiver for multiple facilities/locations in one submission will not be considered.

Facility Point of Contact