Wynnewood Maintenance Request Form

FULL NAME*

First NameLast Name

PHONE NUMBER*

ex: 555-555-4256

E-MAIL*

ex: myname@example.com

APARTMENT NUMBER*

PETS RESIDE IN YOUR APARTMENT?*

WYNNEWOOD HOUSE HAS PERMISSION TO ENTER YOUR APARTMENT?*

YesNo

MAINTENANCE REQUEST*

Please add as much detail as possible (including room/location of area needing repair).

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If you are feeling unwell, we appreciate you waiting to enter a non-emergency maintenance request until you are feeling better. All emergency maintenance requests must be called in to the office or the emergency maintenance line.

Does anyone in your household have any one of these symptoms: fever or chills, cough, shortness of breath/trouble breathing, fatigue, diarrhea, muscle or body aches, headache, nausea or vomiting, new loss of taste or smell, sore throat, congestion or runny nose?*

YesNo

IN THE LAST 14 DAYS, HAS ANYONE IN THE HOME/SUITE TRAVELED OUTSIDE THE UNITED STATES?*

YesNo

Has anyone in your household had any of the previous symptoms in the last 72 hours?*

YesNo

Do you or someone in your household currently have COVID-19 or have a pending COVID-19 test?*

YesNo

Do you or a member of your household have a pending COVID-19 test?*

NoYes

Do you or a member of your household currently have COVID-19?*

YesNo

Have you or a member of your household been in contact with someone suspected or confirmed to have COVID-19 within the last 10 days?*

YesNo

Is anyone in your household considered an essential or life sustaining worker?*

YesNo

In the past 14 days, has anyone in your household traveled out of state?*

YesNo

In the past 14 days, has anyone in your household been quarantined or self-quarantined by a health care professional?*

YesNo

In the past 14 days, has anyone in your household been quarantined?*

YesNo

Have all members of your household been following the governor’s ‘stay at home’ order?*

YesNo

Have all members of your household been practicing social distancing and mask wearing outside of your household?*

YesNo

Our maintenance team member will wear a face mask in your home if you prefer. Please indicate whether you prefer they wear a mask. At any time, during the visit please feel free to request they wear a mask.*

YesNo

Please verify that you are human*

If this is a Maintenance EMERGENCY and the office is closed please call the Emergency Maintenance phone number at 610-642-5253. All calls will be addressed during Wynnewood House Office Hours which are Monday-Friday: 9:00AM-6:00PM.