A SINGLETRACK MIND COVID-19 SCREENING QUESTIONNAIRE
The safety of you and our clients is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our workforce, we are asking everyone to complete and submit this questionnaire prior to attendance. Please know your responses will be reviewed prior to your approved participation.
Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you, our employees, and other clients.
Date Signed: January 27, 2021
1) Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Please take your temperature before you answer this question.)
I hereby certify that the responses provided above are true and accurate to the best of my knowledge.
Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. The information on this form will be maintained as confidential.