Santa Squad Inc.- Daily COVID-19 Questionnaire
REQUIRED FOR ALL ON SET PERSONNEL
By filling out this questionnaire you acknowledge and agree that Santa Squad, Inc. will receive and review your answers and medical information and you consent to such disclosure
* Required
Name
*
First Name
Last Name
1. Was your self taken temperature below 100.4F/38C?
*
YES
NO
Email address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
TODAY'S DATE
*
-
Month
-
Day
Year
Actual Date of Work day
2. In the last 14 days, have you or any other member of your household had any of the following symptoms?
*
Fever of 100. 4 degrees fahreheit/38 degrees celsius or greater
Cough or shortness of breath
Diarrhea, stomach pain or abnormal loss of appetite
Extreme fatigue or muscle aches
Chills with or without shaking
None of the above
3. In the last 14 days, have your or a member of your household tested positive for or been diagnosed by a healthcare provider with COVID-19?
*
YES
NO
4. In the last 14 days, have you or a member of your household been instructed to self-quarantine by a health official or healthcare provider?
*
YES
NO
5. In the last 14 days , to your knowledge, did you or any other member of your household have Close Contact with a confirmed case or probable case of COVID-19 infection? Close Contact is defined as:
*
Being within approximately 6 feet (2 meters)(or any distance required by local law) of a COVID-19 case for a prolonged period of time; close contact can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room with COVID-19 cases; or
Having direct contact with infectious secretions of a COVID-19 case (ie.g. being coughed on).
None of the above
6. In the last 14 days, did you or any other member of your household work in or attend a healthcare facility where patients with COVID-19 were being treated?
*
YES
NO
7. In the last 14 days, have you or any other person in your household travelled outside of the province
*
YES
NO
Submit
Should be Empty: