Super Germs Form -- (FAMILY)

1

The following questions are regarding your preferences, comfort level, and requested-sitter-specifications. This is collected to keep everyone healthy and safe in every season. We will reference this info during our matching process, but will come to you directly on a case by case basis.

2

Your Name:* This field is required.You, the person completing the form.

First Name

Last Name

3

The Family Name:* This field is required.Any/all last names associated with your CSSitters account.

4

Are the adults in your home fully vaccinated against Covid?Fully vaccinated is 2 initial shots (or J&J 1 shot).

All adults are fully vaccinated against Covid, and have eligible boosters.

All adults are fully vaccinated against Covid.

The adults in our home are not vaccinating.

Other

5

Are the (eligible) children in your home fully vaccinated against Covid?Fully vaccinated is 2 initial shots (or J&J 1 shot).

All eligible children are fully vaccinated against Covid, and have eligible boosters.

All eligible children are fully vaccinated against Covid.

We do not plan on vaccinating the children.

Other

6

Does your family get the Influenza vaccine (flu shot)?

All eligible family members get the flu shot every season.

Only the adults in our family get the flu shot every season.

Only the children in our family get the flu shot every season.

Our family does not get the flu shot.

Other

7

Do your require your Super Sitters to be fully vaccinated against Covid?* This field is required..

We request that ALL Super Sitters in our home be fully vaccinated against Covid.

No, we are indifferent to our Super Sitters be fully vaccinated against Covid.

8

Do you require your Super Sitters to be boosted against Covid?* This field is required.Per most recent CDC guidelines.

We request that ALL Super Sitters in our home have a Covid booster.

We would love to have Super Sittersbe boosted against Covid, but don't require it.

We are indifferent to our Super Sitters being boosted against Covid.

9

How are you handling Covid at the current moment?* This field is required.

We feel our household is being extremely cautious concerning Covid.

We feel we are being appropriately cautious based on current information and data.

We feel like our life is back to the way it was before Covid.

10

Do your require your Super Sitters to have a Flu Shot?* This field is required.For the current season.

We request that ALL Super Sitters in our home have a current Flu shot.

We would love to have Super Sitters that have a current Flu shot but we don't require it.

We are indifferent to our Super Sitters having a current Flu shot.

11

Do your require your Super Sitters to have a TDap Vaccine?* This field is required.Within the last 10 years.

We request that ALL Super Sitters in our home have a TDap vaccine.

We are indifferent to our Super Sitters having the TDap vaccine.

12

At this time, do you have any travel planned?We understand plans shift and change, but please provide any info you can in regards to future travel plans you know of at this time.

13

At this time, are you planning on attending any big events?We define "big" as 250 people or larger. Weddings, concerts, parties, we wanna hear about them!

14

Will you allow Super Sitters to wear a mask in your home?* This field is required.For general placements OR if there is sickness present.

If it makes our Super Sitter more comfortable, we will be fine if they want to mask.

No, we do not allow masks to be worn in our home.

Other

15

Baseline Sickness: Sniffles, runny nose, and some sort of dry cough (no fever) - AKA the "Chicago Winter Cold". The cold that is prevalent in parents, kids, & those around children, expecially during the winter months.

This 'Baseline Sickness' means that the agency, families, and sitters understand that while working with kids, or having kids in your home, this "Baseline Sickness" is to be expected and is not a barrier to work, or to placement confirmation, unless shared with the agency separately during intake.

16

Covid Exposure: It is the agency's opinion that at this point, anyone exisiting in any public space these days has been exposed to Covid, even if they have not been told specifically about an exposure.

If a sitter/family/child is exposed to a positive Covid case, it is expected that person will test for Covid and relay this information to the agency and/or the sitter/family.

If the family, child, and/or sitter exposed is testing NEGATIVE, is otherwise not displaying any symptoms, and is willing to wear a mask, the placement is expected to proceed as booked.

17

Do you feel the "baseline sickness" and "covid exposure" rules should NOT apply to your household?* This field is required.

No

Yes

18

Please share more information here for the agency to understand your exception:* This field is required. Please note: we are not qualifying your exception, we are simply collecting the information in order to match you accordingly. Any information is helpful.

19

Please confirm:* This field is required.

By listing my family as an exception to the Baseline Sickness and Covid policy, I understand that this policy goes both ways. Therefore, if Baseline Sickness or Covid exposure is present in MY home, I AM responsible for paying the cancellation fee to the confirmed sitter.

20

Please confirm:* This field is required.

I understand if a sitter declines to work in a home with "baseline sickness" present, they are NOT due a cancellation fee, and CSS will attempt to find a substitute sitter for the family.

21

Please confirm:* This field is required.

I understand that if a sitter has "baseline sickness", and we the family decline the coverage, we are responsible for the cancellation fee due to the sitter.

Other

22

Please confirm:* This field is required.

I understand If a sitter declines to work in a home that has been exposed to Covid but where all parties are testing negative and willing to mask, they are NOT due a cancellation fee, and CSS will attempt to find a substitute sitter for the family.

23

Are you comfortable with regular sitter sickness (WITH the confirmation of a negative Covid test)?* This field is required.i.e. sniffles, mild cold-like symptoms

Yes, we are comfortable with a sitter proceeding to come with mild sickness symptoms.

Yes, we are comfortable with a sitter proceeding to come with mild sickness symptoms as long as the sitter is masked.

No, we would not like any sitter experiencing mild sickness symptoms to come to our house.

24

Please confirm:* This field is required.

I understand that If a sitter has been exposed but has tested negative and is willing to wear a mask, and we the family decline the coverage, we are responsible for the cancellation fee due to the sitter.

25

Please confirm:* This field is required.

I understand that if my home has anything more than "baseline sickness," a sitter may decline to work and I am responsible for the cancellation fees due to the sitter.

26

Please confirm:* This field is required.

I understand that I am responsible for communicating ANY & ALL sickness symptoms or sickness exposures present in the home - adults, child(ren), or guests - to the sitter and/or the agency PRIOR to the start of any placement.

27

Please verify everything on this form is true to the best of your knowledge at this time.* This field is required.One last thing...

Yes, I agree that all of this information is true to the best of my knowledge at the time of completion.