COVID-19 Screening Questionnaire, Showing Guidelines & Disclosure
To Be Completed Prior To Your Appointment
Email Address * *
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: *
Enter Mobile Phone Number *
Real Estate Brokerage Name, If Applicable
Property(s) Visiting *
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? *
Have you tested positive for COVID-19 in the past 14 days? *
Have you experienced any symptoms of COVID-19 in the past 14 days? *
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. *
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 *
Submit
Never submit passwords through Google Forms.
This form was created inside of Keller Williams Realty, Inc.. Report Abuse