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PRE-SHIFT EMPLOYEE & ENTERTAINER COVID-19 SCREENING QUESTIONNAIRE

Upon arrival at the workplace, take each employee or entertainer’s temperature using the hand thermometer.  Make a visual inspection of the individual for signs of illness, which could include flushed cheeks or fatigue, and ask the following questions:

In the past 24 hours, I have NOT experienced the following sympton

Fever:   

I Agree
                                            

Fatigue:                                   

I Agree
   

Chills: 

I Agree
                                                                                                          

Cough: 

I Agree
                                              

Sneezing: 

I Agree
                               

Loss of Smell or Taste:

I Agree
                                                                                          

Muscle Aches and Pains: 

I Agree
                 

Sore Throat:

I Agree
                          

Shortness of Breath:

I Agree
                                                                                         

Diarrhea: 

I Agree
                                          

Headaches:

I Agree
                                                                                        

 

I attest that the foregoing information is true and correct.I further understand and accept that AEI Enterprises Inc. and its affiliated entities*, executives, officers, employees and contractors cannot guarantee my safety while working or performing at our establishment. I promise not to seek compensation or initiate legal action against AEI Enterprises Inc., or any of the above-named entities or individuals, for any harm suffered by me in visiting this establishment.          

I Agree
                                                                   

First Entertainer/Employee Name
First Name*
Last Name*
Phone*
First Entertainer/Employee Age Acknowledgment*
First Entertainer/Employee Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Entertainer/Employee Information
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes
First Entertainer/Employee Signature*
Second Entertainer/Employee Name
First Name*
Last Name*
Entertainer/Employee Date of Birth*
Date of Birth
Second Entertainer/Employee Information
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes
Third Entertainer/Employee Name
First Name*
Last Name*
Entertainer/Employee Date of Birth*
Date of Birth
Third Entertainer/Employee Information
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes
Fourth Entertainer/Employee Name
First Name*
Last Name*
Entertainer/Employee Date of Birth*
Date of Birth
Fourth Entertainer/Employee Information
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes
Fifth Entertainer/Employee Name
First Name*
Last Name*
Entertainer/Employee Date of Birth*
Date of Birth
Fifth Entertainer/Employee Information
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes
Sixth Entertainer/Employee Name
First Name*
Last Name*
Entertainer/Employee Date of Birth*
Date of Birth
Sixth Entertainer/Employee Information
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes
Seventh Entertainer/Employee Name
First Name*
Last Name*
Entertainer/Employee Date of Birth*
Date of Birth
Seventh Entertainer/Employee Information
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes
Eighth Entertainer/Employee Name
First Name*
Last Name*
Entertainer/Employee Date of Birth*
Date of Birth
Eighth Entertainer/Employee Information
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes
Ninth Entertainer/Employee Name
First Name*
Last Name*
Entertainer/Employee Date of Birth*
Date of Birth
Ninth Entertainer/Employee Information
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes
Tenth Entertainer/Employee Name
First Name*
Last Name*
Entertainer/Employee Date of Birth*
Date of Birth
Tenth Entertainer/Employee Information
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes
Parent or Guardian's Email Address
Email
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
Parent or Guardian's Information
Have you recently been in close contact with anyone who has exhibited any symptoms of COVID-19 or has tested positive for COVID-19?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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