To my knowledge, I have not been in direct contact with someone who is an active carrier of COVID-19 or is showing the symptoms of COVID-19. I am not showing the symptoms of COVID-19. True ___ Not True ___ If untrue, explain: In the last two (2) days, I have not been diagnosed with, or live in the same household with a person diagnosed with or exposed to Salmonella typhi, Shigella spp, Escherichia coli 015:H7, or Hepatitis A Virus, or have been exposed to an outbreak caused by Salmonella, E-coli, or Hepatitis A; or have symptoms of illness such as diarrhea, fever, vomiting, sore throat with fever, or jaundice. I have no lesion containing pus, such as a boil or a wound that is open or draining, that may be exposed to food that cannot be adequately protected and covered by an impermeable glove. True ____Not True ___ If untrue, explain: I am not chewing gum, candy, tobacco products, or have any food or drink with me, in my pockets, or on my person in any way. I understand that handling any food, touching my mouth, face, covering a sneeze or cough, or touching any unsanitary surfaces such as a cell phone, may contaminate the food. True _______ Not True ________ If untrue, explain: I have washed and sanitized my hands and arms and will continue to do so if I need to leave the packing event to use the bathroom or if I come in contact with any unsanitary surface such as covering a sneeze or cough, shaking an unsanitized hand or touching a cell phone. I will leave all personal belonging in an area away from the packaging lines. True _______ Not True ________ If untrue, explain: The above is a true statement and as best I understand I am safe to package this food for consumption. *Signature required in-person