COVID-19 Screening Questionnaire, Showing Guidelines & Disclosure
To Be Completed Prior To Your Appointment
Sign in to Google
to save your progress.
Learn more
* Required
Email Address *
*
Your answer
Screening Questionnaire
The purpose of the screening questionnaire is to assist the Dept of Health with tracking and tracing COVID-19 exposure and prevent further outbreaks.
Enter Name:
*
Your answer
Enter Mobile Phone Number
*
Your answer
Real Estate Brokerage Name, If Applicable
Your answer
Property(s) Visiting
*
Your answer
Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has had symptoms of COVID-19?
*
Yes
No
Have you tested positive for COVID-19 in the past 14 days?
*
Yes
No
Have you experienced any symptoms of COVID-19 in the past 14 days?
*
Yes
No
I Agree that in the event that I become symptomatic and/or test positive for COVID-19 within 48 hours of the last visit to the property, I will notify the real estate agent immediately for proper tracking and tracing.
*
Yes
No
In the last 14 days did you return from a trip to a designated state that has a significant community COVID spread as per the Governor's Travel Advisory?
https://coronavirus.health.ny.gov/covid-19-travel-advisory
*
Yes
No
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Keller Williams Realty, Inc..
Report Abuse
Forms
