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Health & Safety Questionnaire
Name
*
Email
*
Phone Number
*
Have you tested positive for Covid-19?
*
Yes
No
In the last fourteen (14) days, have you come into close contact (i.e. within six (6) feet) of any person who you know has tested positive for COVID-19?
*
Yes
No
Do you have have reason to believe that anyone you have come into close contact with may have COVID-19 nor have you been exposed to COVID-19 in the last fourteen (14) days?
*
Yes
No
Have you, or anyone in your household, experienced any of the following symptoms in the past fourteen (14) days: cough, shortness of breath, difficulty breathing, fever, chills, muscle pain, sore throat, nausea or vomiting, or diarrhea or new loss of taste or smell?
*
Yes
No
Did you take your temperature before filling out this waiver and your temperature was higher than 100.4 degrees Fahrenheit?
*
Yes
No
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