Staff Health Screening Questionnaire

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Email *

Name *

MOBILE/HOME PHONE NUMBER *

MAILING ADDRESS

I agree to indemnify, defend, and hold harmless the Released Parties from and against any and all costs, expenses, damages, claims, lawsuits, judgements, loses, and or liabilities (including attorney fees) arising either directly or indirectly from or related to all claims made by or against any of the Released Parties due to bodily injury, death, loss of use, monetary loss, or any other injury from or related to my use of the Pal-O-Mine facilities, tools, equipment, individuals, or materials, whether caused by the negligence of the Released Parties or otherwise specifically related to COVID-19. *

Agree

Disagree

Have you tested positive for COVID-19 within the past 14 days? *

Yes

Have you or household family members had close contact with or cared for someone diagnosed with COVID-19 within the last 14 days? *

Yes

Have you or household family members experienced any cold or flu-like symptoms in the last 14 days (fever, cough, sore throat, respiratory illness, difficulty breathing)? *

Yes

Have you or anyone else in your household travelled outside of New York State in the last 14 days? *

Yes

SIGNATURE *

DATE *

YYYY

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

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