Gaining Ground Volunteer COVID-19 Screening Form

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To be filled out by either:
- Group Leader, certifying for ALL accompanying individuals
- Individual Volunteers (15+ years old)

Thank you for helping us keep our volunteer program open by protecting the health and safety of our farmers, volunteers, staff and food recipients. Please be sure to click "Submit" at the bottom of the form when done.

By digitally signing this form, you self-certify that you and all individuals volunteering with you:

*Do not currently have, and have not had in the past 24 hours, any of the following symptoms: fever (or a measured temperature above 99 degrees Fahrenheit), cough, headache, nausea/vomiting, runny nose, sore throat, loss of taste or smell, or difficulty breathing.
*Have not had close contact with an individual diagnosed with or suspected of having COVID-19. (“Close contact” means living in the same household as a person who has tested positive for COVID-19, caring for a person who has tested positive for COVID-19, being within 6 feet of a person who has tested positive for COVID-19 for at least 15 minutes, or coming in direct contact with secretions (e.g., sharing utensils, being coughed on) from a person who has tested positive for COVID-19, while that person was symptomatic.)
*Are not currently awaiting the results of a coronavirus test.
*Have not traveled outside of the United States within the past 14 days. (Note: If you have traveled within the United States but outside of Massachusetts within the past 14 days, please call our office at 978-610-6086 to discuss this further with one of our staff).
*Have not been asked to self-isolate or quarantine by a doctor or public health official within the past 14 days.
*Have not tested positive for COVID-19 without being cleared as non-contagious by health authorities.
*Have not been treated or hospitalized for presumed COVID-19 without being cleared as non-contagious by health authorities.

Print your full legal name. Your digital signature below certifies that, to the best of your knowledge, you are in compliance with each of the COVID-19 screening criteria listed above on this form. *

Select today's date. *

YYYY

Number of individuals volunteering in your group: *

Group Name (if applicable)

Please indicate if you are partially or fully vaccinated against COVID-19. This is for informational purposes only -- vaccination is not a requirement for volunteering.

Not vaccinated

Partially vaccinated (I have received one dose of an approved COVID vaccine and/or am awaiting full immunity after two doses)

Fully vaccinated (I have received all required doses of an approved COVID vaccine, with final dose administered more than two weeks ago)

Other:

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We look forward to welcoming you to the farm to volunteer! Thank you for your support of Gaining Ground's hunger relief mission. Call (978)-610-6086 or email volunteer@gainingground.org with any questions. - Gaining Ground

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