In our efforts to minimize the transmission and spread of COVID -19, please complete the following questionnaire on behalf of yourself and all individuals within the home, prior to submitting your maintenance request.
1.) Have you or anyone within the home tested positive for COVID – 19 within the last 14 days?
Yes
No
2.) Within the last 14 days did you provide care or have contact with a symptomatic person known or suspected to have COVID-19?
Yes
No
3.) Please select
YES
if
you or anyone
within the home are currently experiencing any of the following symptoms:
Fever
Chills
Cough or worsening of chronic cough
Shortness of breath
Sore throat
Runny nose
Loss of sense of smell or taste
Headache
Fatigue
Diarrhea
Loss of appetite
Nausea and vomiting
Muscle aches
Stuffy nose
Conjunctivitis (pink eye)
Dizziness, confusion
Abdominal pain
Skin rashes or discoloration of fingers or toes
Yes
No
Submit
