COVID-19 HEALTH SCREENING & TRAVEL ADVISORY QUESTIONNAIRE

The New York State Department of Health (DOH) recommends that this screening questionnaire be done remotely whenever possible

As part of the phased re-opening for real estate, the DOH released “Interim Guidance for Real Estate Services During the COVID-19 Public Health Emergency”. Within the document, guidance is provided for screening Sellers/Buyers/Landlords/Tenants prior to showing a property in-person. The purpose of the screening questionnaire is to assist the DOH with tracking and tracing COVID-19 exposure and prevent further outbreaks.

Individuals travelling to NY from a non-contiguous state or CDC Level 2 or higher health notice country are subject to a 10-day quarantine but will have the ability to shorten the quarantine requirement by “testing out” through two negative COVID tests. Information on requirements for “testing out” can be found here: https://coronavirus.health.ny.gov/covid-19-travel-advisory

You are being asked to provide your contact information, such that all contacts may be identified, traced and notified in the event an individual is diagnosed with COVID-19

Full Name *

First Name Last Name

Please indicate if you are entering an office or in person real estate activity? *

Property Address Being Shown

Street Address

Street Address Line 2

City

Agent Name *

Agent Email *

Agent E-mail *

example@warrenhomes.com

Customer Email *

example@example.com

Phone Number *

Area Code Phone Number

Can you receive texts to the phone number provided? *

Yes No

Signer is a: *

Potential Buyer/Tenant Seller/Owner Occupant Service Provider Real Estate Licensee Employee

Please indicate which agent you are working with

Please check all that apply to you: *

have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19 have you tested positive for COVID-19 in the past 14 days have you experienced any symptoms of COVID-19 in the past 14 days have you travelled from a non-contiguous state after 11/4/2020 (If yes answer below) I have completed the mandatory 14-day quarantine or met the requirements to “test out” of the 14-day quarantine None apply

Please check all that apply to you:

have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19 have you tested positive for COVID-19 in the past 14 days have you experienced any symptoms of COVID-19 in the past 14 days have you travelled from a non-contiguous state (If yes answer below) I have completed the mandatory 10-day quarantine or met the requirements to “test out” of the 10-day quarantine None apply

Please check all that apply to you:

have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19 have you tested positive for COVID-19 in the past 14 days have you experienced any symptoms of COVID-19 in the past 14 days None apply

Non Contiguous State

In the event you become symptomatic and/or test positive for COVID-19 within 48 hours of the last visit to the property, you must notify the real estate agent immediately so proper tracking and tracing can be completed.

Please verify that you are human *