A|G Photography COVID-19 Client/Staff Screening Questionnaire

A|G Photography COVID-19 Self Screening Questionnaire

REQUIRED FOR ALL STAFF/CLIENTS/MEMBERS BEFORE ARRIVING ON LOCATION/SET WITH A|G.
As we return to work during the COVID-19 pandemic, AARON GREENSPAN (A|G Photography) has implemented a Health and Safety Policy to reduce and prevent the spread of COVID-19 in the workplace.

We are taking additional measures to protect all employees, independent contractors, and anyone on set/location participating in the shoot from the spread of COVID-19.

In accordance with such policy, 24 hours prior to any A|G shoot, and again on the day of the shoot, all individuals must fill out the following form to be on set/location.

Anyone who has any symptoms, has had close contact with anyone who has tested positive within the previous 14 days, or has travelled internationally within the previous 14 days, should stay home, and is asked to contact A|G as soon as possible.

You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT come enter the outlined location of said shoot.

If you experience any symptoms or answer “YES” to any of these questions, you must immediately contact your health care professional for recommended next steps AND notify your manager and HR.

1) Have you had any of the following symptoms in the last 24 hours?*

	Yes	No
Cough
Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours:*

	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

If you answered “Yes” to question one, please DO NOT come into work. You should:
- Self-quarantine for at least 10 days from the date on which you first experienced any of the above symptoms; AND
- Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
- Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 14 days have you:*

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

If you answered “Yes” to any part of question two, please DO NOT come into work. You should self quarantine for at least 14 days.

I certify to the best of my knowledge; this information is accurate.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

A|G Photography COVID-19 Self Screening Questionnaire