ESB MACC COVID Health Questionnaire
The safety of our patrons is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our community, we are asking everyone to complete and submit this questionnaire prior to entering the ESB-MACC. Please do not enter the MACC until your responses have been reviewed and your entry has been approved.
Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and our guests. Parents please fill one form for everyone in your family/household.
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Adult Name(s) *
Email *
Phone Number *
Names of Minor Children
Are you or anyone in your family/household currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? Fever, chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and/or diarrhea *
Have you or anyone in your family/household been in close contact with someone w/confirmed COVID-19 diagnosis? *
Do you or anyone in your family/household have a confirmed COVID-19 diagnosis? *
If you answered yes to any of the above questions, please do not enter the facility until you have been cleared by a medical professional.
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