Certification of Quarantine

West Virginia State University’s Quarantine Guidelines, call for a five-day quarantine for domestic travel outside of the state of West Virginia and a 14-day quarantine for international travel.

By completing this form, and signing it below it is my certification and agreement that:

I have isolated myself during this period of time and have only left my residence when absolutely essential, such as for doctor visits;
I fully understand that submission of this Certification of Quarantine under false pretenses (which would include failure to genuinely self-isolated during the listed times) would constitute a fraud upon the University and may make me subject to employee discipline.

Name:

A#:

Email:

I am a member of :

I travelled outside of the state of West Virginia:

Location and dates of domestic travel:

I travelled internationally. :

Location and dates of international travel:

I am self quarantining for the following dates:

Signature:

Security code:

Enter security code:

Leave issues and concerns for leave-eligible employees, for leave provisions as provided by the Families First Coronavirus Response Act (FFCRA), and for accommodations under the Americans with Disabilities Act (ADA) should be addressed to HR at hr@wvstateu.edu.

This certification of quarantine is only accepted as valid by the University to document an absence of up to two calendar weeks. A physician’s note is required for absences of greater length, and FMLA CERTIFICATION MAY BE REQUIRED. Special circumstances may be reviewed by HR.

Certification of Quarantine

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