Title Page
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Conducted on
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Prepared by
Assessment
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Have you experienced any flu like symptoms in the last 30 days?
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During the Covid-19 Pandemic was your job considered “essential”?
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If you answered “yes” to question 2, please answer the following question(s): While working were you able to maintain a social distance of 6ft or more from other employees/employers?
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Did your employer implement safety protocols such as: Handwashing, disinfecting, social distancing, wearing masks and also the frequent check of body temperature?
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Have you traveled within the US in the last 14 days?
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Have you traveled outside the US within the last 14 days?
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Do you work in the medical field?
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If you answered yes to the question above and you DO work in the medical field did you come in contact with a patient being treated for Covid-19 or have you been exposed to Covid-19 in anyway?
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If you did not work during the pandemic this question applies to you: Have you come in contact with anyone who was exposed or treated for Covid-19?
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Do you think you have followed state shut down orders and quarantine guidelines to the best of your abilities in the last 30 days?
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Do you sanitize regularly with soap, hand sanitizer or disinfectant?
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Moving forward, Would you like to continue May’s Cleaning Schedule?
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Would you feel safer or less at risk if we wore mask and gloves when entering your home?
