COVID19

COVID-19 Introduction, Screening & Prevention

COVID-19 Introduction

COVID-19 Office Visitor / Event Participant Screening Questionnaire

If you would like to fill the form manually and submit while coming to Office/Event, click the icon to the right for printing.If you would like to fill the form manually and submit while coming to Office/Event, Click here

During this challenging time, Outside2Inside’s priority remains the safety of all of us. While ensuring compliance with state & local guidelines, we would like to schedule any visits to the Outside2Inside Office / events keeping in mind both the safety of the visitors and Outside2Inside members. So, your co-operation in this regard is much appreciated.

The safety of our everyone is Outside2Inside organization’s highest priority. As the corona virus (COVID-19) pandemic continues and in order to prevent the spread of the corona virus and reduce the potential risk of exposure to people visiting our Outside2Inside office, we are asking everyone to complete and submit this questionnaire prior to entering Outside2Inside’s Office. Kindly fill this questionnaire before coming to the Office. 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 and our others.

    O2I Visitor/Event Participant Details
    QUESTIONNAIRE
    1. Do you have any fever? (Any temperature 100.4 F or greater is considered a fever.)*
    2. Do you have any of the following Symptoms?* FeverCoughShortness of breath or difficulty breathingChillsRepeated shaking with chillsFatigueMuscle or body achesHeadacheSore throatNew loss of taste or smellVomitingDiarrheaNone of the above
    3. Do you have a new or worsening cough today?*
    4. Is anyone in your home currently sick or quarantined?*
    5. In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
    6. In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
    7. Has anyone in your home been in direct contact with anyone with the COVID-19 virus?*
    8. Have you been tested for COVID-19 and are waiting to receive test results?*
    9. Have you have tested positive for COVID-19, or are you presumptively positive for COVID-19 based on your health care provider’s assessment or your symptoms?*
    10. In the past 14 days, have you been on a commercial flight or traveled outside of the United States?*
    11. In the past 14 days, have you been in close proximity to anyone who has been on a commercial flight or traveled outside of the United States?*
    12. Is there any reason why you feel you are at higher risk of contracting COVID-19 or experiencing complications from COVID-19 by entering the facility?*
    If you answered "Yes" or "Other" to any of the questions above, please provide a brief explanation below. Otherwise type "NA".
    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. Should you have any questions please contact contact@outside2inside.com
    Guidelines to be followed during Office Visit / Event:
    1. At this time, we would like to limit the number of people visiting the Outside2Inside Office to a maximum of 10 or less to practice effective social distancing.
    2. Each person should wear a Mask & if possible gloves for both hands. Kindly bring them with you, otherwise you will not be allowed inside the Office.
    3. Mask and gloves to be worn at all times during the Outside2Inside Office visit/event.
    4. Kindly trash your used mask and gloves in the appropriate marked trash cans meant for them during your visit.
    5. Each person should maintain 6 Ft distance from another person at any time during the visit/event.
    AGREEMENT AND SIGNATURE
    I HEREBY CERTIFY THAT THE RESPONSES PROVIDED ABOVE ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I AGREE TO FOLLOW ALL GUIDELINES LISTED ABOVE WITHOUT FAIL. I ALSO HAVE READ AND AGREE TO THE DISCLAIMER (HTTPS://OUTSIDE2INSIDE.COM/DISCLAIMER)
    I agree
    Signature*
    Please try to put your full legal signature as much as possible within the above box. If you find it difficult to sign in the above box for some reason, make sure to put at least your initials in the above box.

    Either way, by signing this form electronically, you are agreeing that your electronic signature is the legal equivalent of your manual signature.

    * - Required Fields

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