COVID-19 Health Screening Questionnaire for Sharon Quataert Realty
**This questionnaire is mandatory for all parties who enter our listings including seller/landlord clients, agents, buyers/tenants and all Sharon Quataert Team clients/buyers/sellers. Buyer Agents - Please fill out your and your buyer(s)' responses and sign to certify the answers are true OR send the link directly to your buyers to complete***
Property address you are visiting
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Name of Party 1
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First Name
Last Name
Name of Your Agent
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Have you tested positive for COVID-19 in the past 14 days?
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Yes
No
Have you experienced any symptoms of COVID-19 in the past 14 days?
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Yes
No
Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or anyone who has had symptoms of COVID-19?
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Yes
No
Name of Party 2
First Name
Last Name
Have you experienced any symptoms of COVID-19 in the past 14 days?
Yes
No
Have you tested positive for COVID-19 in the past 14 days?
Yes
No
Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or anyone who has had symptoms of COVID-19?
Yes
No
The above party/parties agree(s) to disclose if they become symptomatic and/or they test positive for COVID-19 within 48 hours of the last visit to their property *
*
Yes
On January, 30 2020 the World Health Health Organization (WHO) designated COVID-19, outbreak as a Public Health Emergency of International Concern. On January 31, 2020, the United States Health and Human Services HHS) Secretary declared a public health emergency for the entire United States and on March 7, 2020, Governor Andrew Cuomo declared a State disaster emergencty for the entire State of New York. Empire State Development has determined that real estate services, including appraisals, inspections and other services necessary to complete a transfer of real property, may be conducted in-person for those regions that have entered Phase 2 of the reopening so long as required health and safety precautions set forth in the Interim Guidance Document published by ESD and the Department of Health are followed. It may become necessary for a real estate licensee, inspector, appraiser, buyer, tenant or other third party to access the Propery. Such access raised the potential for liability resulting from the exposure to COVID-19. By agreeing to permit such parties to enter the Property or by agreeing to enter the Property, all parties acknowledge there is an assumption of exposure to COVID-19 and any and all consequences and/or injury which may result from such exposure, including but not limited to, physical and/or psychological injury, pain, suffering, illness, temporary or permanent disability, death or economic loss. This disclosure will help you to make informed choices about access to the Property during the Emergency. This disclosure will help you make informed choices about access to the Property during the Emergency. By checking the box below, I acknowledge receipt of this COVID-19 Disclosure Statement. *
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I acknowledge receipt of this COVID-19 Disclosure Statement
Signature of Party 1
Submit
Should be Empty: