COVID-19 Questionnaire
COVID-19 Health Questionnaire
All cast and crew members are required to complete this questionnaire before each rehearsal/performance. (If there are multiple rehearsals scheduled on a single day, only one form is required for that day.) We will be taking all cast and crew temperatures at the door before being allowed to enter the space. Thank you for your cooperation!
First and Last Name *
Which production are you a part of? *
Do you have a fever (100.4 F* / 38 C* or higher), feel feverish, or have chills, a cough, or difficulty breathing? *
Within the last 3 days, have you developed symptoms of muscle aches (not due to recent excercise), fatigue, headaches, sore throat, vomiting, or diarrhea? *
Have you experienced a new loss of the senses of taste or smell? *
Have you been in close contact with anyone suspected or diagnosed as having COVID-19, or who is currently subject to health monitoring for possible exposure to COVID-19? *
Have you been in contact, in the last 14 days, with someone that is confirmed to be a case of COVID-19? *
Have you traveled, in the last 14 days, to any area in the United States that is included in the top 5 most affected states determined by the CDC with COVID-19? *
Have you traveled from or through China, including Hong Kong or Macau, in the past 14 days? *
"By signing this form, you certify that the above declaration is true and correct and that any dishonest answers may have serious public health implications. On behalf of the Brightstone Productions Staff, thank you for taking the time to complete this questionnaire."
Signature *
Date *
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy