Amanda Hibbert Photography COVID-19 Daily Questionnaire

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Safety is our top priority. To that end, Amanda Hibbert Photography is asking the following health screening questions to ensure a safe work environment. Everyone must answer these questions before they arrive to the studio. Remember, if you are sick or exhibiting symptoms of COVID-19 (fever of 100.4˚ or greater, chills, cough, fever, difficulty breathing, muscle aches, sore throat, diarrhea, recent loss of taste or smell), or if someone you live with has been lab-confirmed diagnosed with COVID-19 within the last 14 days, you must not report to work.

The information in this questionnaire or any report generated from information contained in the questionnaire is the sole property of Amanda Hibbert Photography. Any designated person that would need to be furnished with this information to carry out their duties must return the information to Amanda Hibbert Photography and may not retain the information.

电子邮件地址 *

Date *

年

月

日

What is your first name? *

What is your last name? *

Who/what is the client/project? *

Do you live in the same household with, or have you had close contact with someone who in the past 14 days was diagnosed with COVID-19 or had a test confirming they have the virus? *

Yes

Within the last 14 days have you taken a COVID-19 test? *

Yes

Within the last 14 days have you been diagnosed with COVID-19 or had a test confirming you have the virus? *

Yes

Have you had any one or more of these symptoms today or within the past 24 hours, which is new or not explained by a pre-existing condition? Fever of 100.4˚ or greater, Chills, or Repeated Shaking/Shivering, Cough, Sore Throat, Shortness of Breath, Difficulty Breathing, Feeling Unusually Weak or Fatigued, Loss of Taste or Smell, Muscle Pain, Headache, Runny or Congested Nose, Diarrhea *

Yes

Have you traveled outside San Francisco County within the past 14 days (please answer 'Yes' or 'No')? If yes, please list. *

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