COVID-19 Private Inspections Disclosure Form

This form is intended to reduce the spreading of COVID-19 within the area. Please fill out the form in every inspection that you make for any property.

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Address of Property to be Inspected

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you (or any member in the property to be inspected) had any symptoms relating to COVID-19 in the last 14 days (i.e. fever, cough, shortness of breath, loss of taste and/or smell, chills)?

Have you (or any member in the property to be inspected) had any exposure with any person who has been diagnosed with COVID-19 in the last 14 days?

Have you (or any member in the property to be inspected) been treated for COVID-19 in the past 90 days?

Have you received a full-dose vaccine for COVID-19?

Are there any members in the property to be inspected who have not received a vaccine for COVID-19?

I hereby declare that the information I have provided above is true and correct to the best of my knowledge. I understand that my visit may raise potential exposure to COVID-19.

I acknowledge and take the risk and possibility of exposure to COVID-19 for my visit and take any and all consequences to such. I shall not hold liable the company/organization, its agents, affiliates, or employees for any damages or causes of action which I may have against them.

Signature

Date