Hands in Service Client Covid19 Screening Tool

CLIENT

COVID-19 CONSENT FORM
I understand the novel coronavirus causes the disease known as COVID-19. I also understand that the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I confirm that I have taken into consideration my own health risks (i.e.: immunocompromised or high-risk.)
I consent to Hands in Service volunteers being in my home to complete basic housekeeping.

Yes No
Have you, or anyone in your household tested positive for Covid-19?

Yes No
Do you, or anyone in your household, have any new or worsening symptoms including: a fever, chills, cough, shortness of breath or difficulty breathing, sore throat, runny nose, muscle aches or a headache?

Yes No
Have you, or anyone in your household, travelled outside of Canada in the past 14 days?

Yes No
Have you, or anyone in your household, had close contact with a person with Covid-19, probable or confirmed?

Yes No
I will respect a physical distance of at least 2 m./6 ft. while volunteers are in my home.

Yes No
I understand that Hands in Service is not accountable/responsible for any health issues I may experience any time after the in-home service.
Electronic Signature:

First Name Last Name
Date:

Month Day Year
Date
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

CLIENT