Completion of this form will be required upon arrival
| This assessment must be completed by all persons entering this DESANTIS HOMES facility. You may not be permitted to enter this facility if you do not complete this form. The information you provide will be used by DESANTIS HOMES to evaluate and respond to health and safety risks associated with Covid-19 exposure at our facilities. Where necessary for public health and safety reasons, DESANTIS HOMES may use the information you provide in internal and external communications related to the COVID-19 pandemic, however DESANTIS HOMES will not identify you in any communication by name unless required by law. Completed forms will be retained by DESANTIS HOMES in a secure and confidential manner for the duration of the risk pandemic.
Visitor Name: _____________________________________________________ Visitor Name: _____________________________________________________ Visitor Name: ______________________________________________________ |
| Phone Number: _____________________________________________________
Email: _____________________________________________________ |
| Date: ______________________________________________________ |
| Name of Host / Person(s) to Visit: _______________________________ |
| Please check the appropriate box:
1. Are you currently experiencing any of the following symptoms? □ Fever □ Cough □ Shortness of Breath □ Runny Nose □ Sore Throat □ Body Aches
|
□ Yes □ No |
| 2. Have you been in close contact with a known or suspected case of COVID-19 within the last 14 days?
Close Contact is defined as being within 2 metres (6ft) of the person, having cared for, having lived with or spent more or less 15 minutes with the person.
|
□ Yes
□ No |
| 3. Have you travelled to or from an area of current COVID-19 outbreak within the last 14 days?
Area(s) :
|
□ Yes
□ No |
| 4. Do you intend to travel outside of the country in the upcoming weeks? Scheduled departure date:
Destination: |
□ Yes
□ No |
| If you have answered Yes to questions 1,2 or 3, you may not enter the sales office until at least 14 days after you are free of fever/symptoms without the use of medication and you may want to seek medical attention. Thank you for your understanding and cooperation. |
