Health Screening Agreement

Health Screening Agreement
For the purposes of health and safety, the local public health department requires individuals to be screened for symptoms of COVID-19. During the time which may cause interruption of activities, the Centers for Disease Control and Prevention (CDC) do not recommend screenings be done by the management. Screening may be conducted after the prior end-of regular day activities.
In this regard, we ask that you complete the information below and have it submitted for preliminary steps for screening as an indication of your understanding and agreement to the performance of screening.
I hereby expressly commit to the screening for symptoms and exposure to COVID-19.

My signature below expresses my full consent to the screening.

Signature
Date

First Name   Last Name
Street Address   Address Line 2
City   State
Zip

Email
Area Code   Phone Number
Should be Empty: