KST's COVID-19 Screening Questionnaire

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The renter disclosure form seeks information from you that we must consider before granting entry into a KST operated space in the circumstance of the COVID-19 virus.

All individual occupants must complete this questionnaire in order to be granted entry into a KST operated space.

In addition to completing this form, you are required to sign and return KST's COVID-19 Waiver before entering a KST operated space.

Please Note: KST's COVID-19 wavier will be emailed to you by a KST Staff member and only needs to be signed once as it will remain on file with us. However, this COVID-19 Screening Questionnaire MUST be complete NO MORE than four hours before EACH rental commences.

It is important that you disclose to KST any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

A weakened or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19.

We thank you for taking the time to complete this questionnaire and we look forward to hosting you in our spaces.

If you have any questions or concerns please reach out to Sondra at Rentals@kelly-strayhorn.org

PLEASE READ EACH QUESTION CAREFULLY

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PLEASE NOTE: The collection of emails on this form is for the sole purpose of communicating any COVID-19 information related ONLY to the event or rental listed on this form below.

Email *

First Name *

Last Name *

Phone Number *

Event or Rental Name *

Which KST operated space will you be entering today? *

Kelly Strayhorn Theater

KST's Alloy Studios

Both

Please indicate the time you will be arriving for your event or rental? *

Time

Have you experienced any of the following symptoms in the past 48 hours: (Please select ALL that apply) *

fever or chills

cough

shortness of breath or difficulty breathing

fatigue

muscle or body aches

headache

new loss of taste or smell

sore throat

congestion or runny noise

nausea or vomiting

diarrhea

none of the above

Required

Within the past 14 days, have you been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with: Anyone who is known to have laboratory-confirmed COVID-19? OR• Anyone who has any symptoms consistent with COVID-19? *

Yes

Are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19? *

Yes

Have you tested positive for COVID-19? *

Yes

Have you been tested for COVID-19 and are awaiting results? *

Yes

Have you traveled outside of PA in the past 21 days? *

Yes

If so, where and when?

'SIGNATURE REQUIRED' I fully understand and acknowledge the above information, risks, and cautions regarding a comprised immune. By typing my initials below with today's date (MM/D/YR), I am hereby signing this document to acknowledge that the answers I have provided above are true and accurate. Please Note: If a guest is under the age of 18, and thus legally incapable of signing a binding contract, the parent or guardian must sign. Please list the guest's name along with the parent or guardians. *

A copy of your responses will be emailed to the address you provided.

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