COVID-19 DAY 1 - SCREENING QUESTIONS & WAIVER

COVID-19 SCREENING QUESTIONS & WAIVER
Full Name *

First Name Last Name
Email *
example@example.com
Which Seminar? *
Day 1 Temp *
PLEASE SELECT YES OR NO AFTER EACH OF THE FOLLOWING QUESTIONS
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit? *

Yes No
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19 *

Yes No
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19? *

Yes No
Have you or anyone in your household been tested for COVID-19? *

Yes No
If yes, date and result of last test

Month Day Year
Date
If you don't work in a hospital setting, have you or anyone in your household visited or received treatment in a hospital, nursing home or long-term care facility? *

Yes No
Have you or anyone in your household traveled on a cruise ship or outside the country in the last 21 days? *

Yes No
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID 19? *

Yes No
I understand the close proximity with other attendees/instructor required in this course and I voluntarily agree to participate in spite of this in spite of the risks it might entail.

In order to best protect all present, I agree to wear a mask during this seminar.

I understand the instructor will not be wearing a mask during power point presentations (for purposes of lecture clarity) but will maintain social distancing guidelines.
SIGNATURE *

Clear
DATE *

Month Day Year
Date
Should be Empty:

COVID-19 SCREENING QUESTIONS & WAIVER