COVID-19 Safety Survey
Please complete this survey before I arrive to your home. IF YOU ARE SICK, PLEASE CANCEL YOUR LESSON.
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Email *
Full name and cell phone number: *
Date of private lesson: *
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Address of private lesson: *
Have you received a vaccine for COVID-19? *
In the last 14 days, has someone in your household been confirmed to have COVID-19? *
Have you traveled outside of New York state in the last 14 days (domestic or international)? *
In the last 24 hours have you experienced chills? *
In the last 24 hours have you experienced coughing? *
In the last 24 hours have you experienced fever? *
In the last 24 hours have you experienced loss of smell or taste? *
In the last 24 hours have you experienced muscle aches? *
In the last 24 hours have you experienced shortness of breath? *
If you answered yes to any of the above, please elaborate.
Date of submission: *
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Time of submission: *
Time
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