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Town of Brookline COVID-19 Self-Certification Form

  1. REVIEW BEFORE TAKING TEMPERATURE AND SIGNING IN.


    • I have no signs of a fever or a measured temperature above 100F/37.7C degrees or greater, a cough or trouble breathing within the past 24 hours.
    • I have not had "close contact" with an individual diagnosed with COVID-19. “Close contact” means living in the same household as a person who has tested positive for COVID-19, caring for a person who has tested positive for COVID-19, being within 6 feet of a person who has tested positive for COVID-19 for about 15 minutes, or coming in direct contact with secretions (e.g., sharing utensils, being coughed on) from a person who has tested positive for COVID-19, while that person was symptomatic in the last 14 days.
    • I have not been asked to self-isolate or quarantine by their doctor or a local public health official.

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