COVID-19 Symptom Screening

Email Address*

Name*

First Last

Phone Number

On which Commerce House job are you working?

What is your title/role?

What is your first day of work on this project?

Do you have any cause to believe that you currently have Covid-19?*

Yes
No

Within the last 14 days, have you been diagnosed with Covid-19 or a test confirming you have the virus?*

Yes
No

Do you live in the same household with, or have you had close contact with someone who in the past 14 days has been diagnosed with Covid-19 or had a test confirming they have the virus?*

Yes
No

Please list any unexplained symptoms that would lead you to believe you have Covid-19 and not just a simple cold or allergies. Symptoms of Covid-19 are listed below. Please check any symptoms you are experiencing.*

Have you traveled on an airplane within the past 14 days?*

Yes
No

By clicking YES below, I affirm that I will notify Commerce House if there are any changes to my above answers that occur after I submit this form and before I arrive to the designated work location.*

Yes
No, I understand that I may be refused entry to the work location and therefore unable to work on this job, as Commerce House has the legal right to rescind this job offer based on the federal Direct Threat Exemption law put in place during this global pandemic.

By clicking YES below, I affirm that should I test positive for Covid-19 within 14 days of working on this contracted job, I am legally required to notify the Covid Compliance Coordinator assigned to my shoot, so they can properly contact trace anyone I may have come in contact with during my contracted time. I understand that if I do not agree to these terms, I may be refused entry to the work location as I am legally required to notify Commerce House. For any concerns, please contact Carley King at carley@commercehouse.com.*

Yes
No, I understand that I may be refused entry to the work location as I am legally required to notify Commerce House so they can properly contact trace anyone I may have come in contact with during my contracted time.