Daily Health Screening Form
Building access is limited. This Coronavirus/COVID-19 screening is required daily prior to entering the Jennings County United Way (United Way) building. Face coverings and use of hand sanitizer upon entry is required.
Name
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First Name
Last Name
Are you fully vaccinated against Covid-19? (Defined as more than two weeks since a second dose, or Johnson single dose vaccine)
yes
no
In the past 14 days, I have experienced...
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Rows
Yes
No
Fever 100.4°F +, Coughing, Headache, Sore throat, Shortness of breath, Non-allergy related runny nose, Unexplained body aches or pain, Muscle pain, Chills, shaking, Unusual fatigue, Recent loss of sense of smell or taste, Unexplained sores on soles of feet, Any other symptom that could be COVID-19 related
Coronavirus/COVID-19 Safeguard Plan. I agree to..
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Wear a face covering and use hand sanitizer
Social Distance—maintain six-foot distance in all directions.
Cleaning and disinfecting—If you touch or use it—you clean it before and after use—including all high touch surfaces. Hand wash for at least 20 seconds.
I attest that...
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I am following all CDC recommended guidelines and limiting my exposure to the Coronavirus. I have not traveled internationally or to a highly impacted area in the last 14 days. I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus. I have not been diagnosed with Coronavirus and not yet cleared as non contagious by public health authorities.
Acknowledgments
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I am not experiencing any symptom of illness whatsoever. I acknowledge the contagious nature of the Coronavirus and that the CDC and many other public health authorities still recommend practicing social distancing and use of a face covering. I further acknowledge that Jennings County United Way has put in place preventative measures to reduce the spread of the Coronavirus. I agree to abide by all preventative measures, policies and procedures. I further acknowledge that United Way can not guarantee that I will not become infected with the Coronavirus. I understand that the risk of becoming exposed to and/or infected by the Coronavirus may result from the actions, omissions, or negligence of myself and others, including, but not limited to, volunteers, and other clients and their families. I voluntarily seek entry to the United Way building and acknowledge that I may be increasing my risk to exposure to the Coronavirus. I acknowledge that I must comply with all set procedures to reduce the spread while in the United Way building, and If I do not I must immediately leave.
Liability waiver and Hold Harmless Agreement
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I hereby release and agree to hold United Way, its volunteers, staff and board of directors, harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act, or that may otherwise arise in any way in connection with entering the United Way building. I understand that this release discharges United Way from any liability or claim that I, my heirs, or any personal representatives may have against the shelter with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, United Way. This liability waiver and release extends to the United Way together with all volunteers, board, donors, clients, owners, partners, and employees. I agree to save and hold harmless any and all persons connected with United Way.
Signature
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Submit
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