Second Line Stages Wellness Questionnaire
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Email *
Name
Date Visiting
MM
/
DD
/
YYYY
Department or Name of Person You are Visiting
I am experiencing COVID-19 symptoms such as a cough, shortness of breath or high temperature
Clear selection
I have been in close contact with someone who may have COVID-19 but is yet to be confirmed
Clear selection
I have been in close contact with someone, such as a family member who is experiencing symptoms and/or has been confirmed positive with COVID-19.
Clear selection
If you answered "yes" to any of the above questions, at this time, you are not permitted to enter the Second Line Campus.
If you answered "no" to the above questions, please respond to the following:
I understand the importance of regular hand sanitizing.
Clear selection
I will keep to the work area designated to me and stay at least 6 ft. from others on campus.
Clear selection
I will wear a mask at all times on campus.
Clear selection
I will inform my supervisor/manager if there are any issues of concern relating to control of the spread of COVID-19 (or other safety issues.)
Clear selection
I consent to having my temperature taken (non-contact) each day upon entering the Second Line campus and understand I may not be able to enter campus if I have a cough or a high temperature
Clear selection
I will inform Second Line Stages by phone if I start to feel unwell at anytime following my visit. (504) 224-2245
Clear selection
I confirm that I have read, understood and been walked through this COVID-19 risk assessment and understand the control measures. All statements made above are correct at the time of answering to the best of my knowledge. I will immediately inform the company of any changes to the declarations made.
Clear selection
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