COVID Lifestyle
A questionnaire to help families better understand your COVID lifestyle.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Do you plan on taking on additional work outside of the position you are applying for? If so, please describe.
*
Do you have a spouse, family member or house mate that you reside with that is currently working at a job that requires them to be on-site, in-person? If so, what type of work do they do? (Please list all individuals that reside in your home and work outside of the home)
*
Who is in your current social circle (i.e. who do you interact with indoors on a daily, weekly, monthly basis?)
*
Briefly describe what precautions you and your family are currently taking to limit your exposure and your chances of contracting COVID-19.
*
Please rate your current comfort level with the following activities.
*
Very
Comfortable
Somewhat
Comfortable
Neutral,
No Opinion
Somewhat Uncomfortable
Avoid Altogether
Restaurants (indoor)
Restaurants (outdoors)
Doctor's, Dentist Visits
Dinner at a Friend or Family Member's House (indoors)
Outdoor Gatherings with Friends & Family
Grocery Store
Haircuts, Nail Salon, etc.
Walking Outdoors
Plane Travel
Hotel, AirBnB
Would you like to explain any of your above answers?
Do you have any upcoming trips, events that the family should be aware of? If so, please explain.
*
Please verify that you are human.
*
Submit
Should be Empty: