Surveypoint

Q1

Name

Q2

Phone Number (mobile/home):

Q3

Name of agent you are working with:

Q4

Address you are entering/viewing:

Q5

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)

Yes

No

Q6

Cough

Yes

No

Q7

Sore throat

Yes

No

Q8

New loss of taste or smell

Yes

No

Q9

Chills

Yes

No

Q10

Head or muscle aches

Yes

No

Q11

Nausea, diarrhea, vomiting

Yes

No

Q12

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?

Yes

No

Q13

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?

Yes

No

Q14

Have you or anyone in your household been tested for COVID-19 and are waiting to receive test results?

Yes

No

Q15

Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms?

Yes

No

Q16

In the past 14 days, have you been on a commercial flight or traveled outside of the United States?

Yes

No

Q17

In the past 14 days, have you been in close proximity to anyone who has been on a commercial 7 flight or traveled outside of the United States?

Yes

No

Q18

Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? If “yes”, please provide a brief explanation.

Yes

No

Q19

Explanation:

Q20

Have you entered New York State after 12:01a.m. on June 25, 2020 from one of the “impacted jurisdictions”? As of 12 pm 6/30/20, these impacted states include Alabama, Arkansas, Arizona, California, Delaware, Florida, Georgia, Iowa, Idaho, Kansas, Louisiana, Mississippi, Nevada, North Carolina, Oklahoma, South Carolina, Tennessee, Texas and Utah. For a current list of states impacted, this is the website link. https://coronavirus.health.ny.gov/covid-19-travel-advisory

Yes

No

Q21

If your answer to #9 is YES, have you self quarantined for a minimum of 14 days after re-entering New York State?

Yes

No

Q22

Covid Screening -Form Fill

Name

Phone Number (mobile/home):

Name of agent you are working with:

Address you are entering/viewing:

Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)

Cough

Sore throat

New loss of taste or smell

Chills

Head or muscle aches

Nausea, diarrhea, vomiting

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?

Have you or anyone in your household been tested for COVID-19 and are waiting to receive test results?

Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms?

In the past 14 days, have you been on a commercial flight or traveled outside of the United States?

In the past 14 days, have you been in close proximity to anyone who has been on a commercial 7 flight or traveled outside of the United States?

Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility? If “yes”, please provide a brief explanation.

Explanation:

If your answer to #9 is YES, have you self quarantined for a minimum of 14 days after re-entering New York State?

Date