Cache Studios | Visitor Health Screening
Please answer the following questions to the best of your ability. Please take note that this is a legal document and it must be completed on the SAME DAY as your class.
Email *
Today’s Date: *
MM
/
DD
/
YYYY
Full Name (First & Last Name) *
Cell Phone # *
Have you been vaccinated? (If you have received 1 of 2 shots, please answer Yes) *
Have you experienced any symptoms of COVID-19 including a fever of 100.4 degrees Fahrenheit or greater, a new cough, new loss of taste or smell, or shortness of breath with in the past 5 day? *
In the past 5 days, to the best of your knowledge, have you been in close contact (within 6 ft for more than 10 minutes) with anyone that is confirmed positive with COVID-19? (Clinical staff who were in appropriate PPE are not considered close contacts in these scenarios) *
In the past 10 day have you traveled internationally or returned from a state identified by New York State as having wide spread community transmission of COVID-19? *
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of CACHE STUDIOS INC. Report Abuse