Date: _________________ Sun Wah Barbecue Restaurant 5039 N. Broadway Chicago, IL 60640 773.769.1254 sunwahbbq@gmail.com Health Declaration Form I hereby certify, represent, and warrant as follows: Within the fourteen (14) days immediately preceding the date of the health declaration form, I HAVE NOT: 1. Tested positive or presumptively positive for or been identified as an asymptomatic carrier of Covid-19; 2. Experienced any symptoms commonly associated with Covid-19; 3. Have been in direct contact with or the immediate vicinity of any person known or now known to have Covid-19. Name Phone # Email Signature *This form will remain private and confidential unless it is necessary to contact trace any Covid-19 cases. Your information will not be used for any other purposes. We will destroy this document after 60 days from the date listed. You may take a picture on your phone for your records if you like.*