Daily Health Screening
You are required to submit this form before visiting India Center for any purpose.
1/1. Have you been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks? *
2/To your knowledge, have you come into close contact (within 6 feet) with someone who has a laboratory confirmed COVID – 19 diagnosis in the past 14 days? * *
3/To your knowledge, have you had contact with persons suspected to have COVID- 19? * *
4/Do you have any of the following: fever or chills, cough, shortness of breath or difficulty breathing, body aches, headache, new loss of taste or smell, sore throat? (CDC list of COVID-19 symptoms: https://www.cdc.gov/coronavirus/2019- ncov/symptoms-testing/symptoms.html ) * *
5/Have you shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks? *
6/ In the past 14 days have you or anyone you live with, traveled to high risk regions in the state or country? *
If you answered "yes" to any of the above 6 questions, please do not visit the center and should see a healthcare provider for evaluation and potential testing.
Before coming to the center, Negative results of an FDA Emergency Use Authorized COVID-19 molecular assay for detection of SARS-CoV-2 RNA from at least two consecutive respiratory specimens collected ≥24 hours apart (total of two negative specimens).
7/ If you begin to show symptoms of COVID-19 within the next the next two weeks, I will contact the India Center of Westchester at Info@indiacenter.us? *
8/. I will practice the CDC Guidelines such as 6 ft social distancing, wear a face mask throughout the entire service; wash hands at a minimum of 20 seconds etc? *
Are you IC member? *
Required
First Name, Last Name/ Phone Number and Email *
Date *
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Disclaimer and Waiver
By signing and filling up this form you acknowledge that you are entering and/or using the premises of the India Center of Westchester Inc. ("India Center") voluntarily, and take full responsibility and liability with respect to any health-related risks, including without limitation, the risks of contracting the COVID 19 virus or other infectious diseases, that may arise as a result of your entering and/or using the premises of India Center. You are responsible for safeguarding your own health and hygiene, and India Center is not in any manner responsible or liable for any health-related issues that may arise as a result of your, or your minor children's participation in teacher lead classes at India Center and/or activities promoted or hosted by India Center. The circulation of information by the India Center and the provision of space for the classes and activities by the India Center is not to be construed as an admission of any liability and/or acceptance of assumption of responsibility by the India Center, its officers, trustees, and employees, jointly and severally.
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