COVID-19 Health Screening Form Your Name (required) Your Email (required) To keep you and our organization safe throughout this pandemic. We ask all our clients the questions prior any onsite installation. In the past 14 days, have you or anyone in your organization traveled to a foreign country or been in close contact (within six feet) with a person who has returned from a foreign country within the past 14 days? * yesno In the past 14 days, have you or anyone in your organization traveled outside of your hometown within the United States without following the recommendations or guidelines to prevent and control the spread of Coronavirus Infection as established by the applicable authorities in the area in which you were traveling (e.g., wearing personal protective equipment such as facemasks and/or adhering to social distancing standards)? yesno In the past 14 days, have you been or anyone in close contact (within six feet) of a person with possible Coronavirus Infection without adhering to the guidelines set forth by the CDC and OSHA for healthcare workers including donning all of the required personal protective equipment such as mask, gloves, and grown? yesno In the past 14 days, have you or anyone in your organization tested positive for or been infected with Coronavirus (COVID-19)? yesno Do you currently have or anyone in your organization (or have you had in the past 14 days) any of the following symptoms: Respiratory illness, fever, cough, headache, sore throat, runny nose, breathing difficulties, loss of sense of smell, unusual fatigue, body aches, or loss of taste? yesno FYI Please keep in mind that upon us entering the lobby of your facility, we have been screened and tested. We are required to wear a mask and practice social distancing. In, addition we will follow any guidelines your organization has placed as well.