COVID-19 Survey The purpose of this survey is to protect the health and safety of everyone who enters our studio. Please provide honest answers to help us create a safe environment. We ask that you please stay home if you are feeling unwell. You will be compensated with a percentage of your rate if you stay home sick. 1. Name * First Name Last Name 2. Phone number * 3. Have you had any of the following symptoms in the past 48 hours? * Check all that apply. Fever or chills Cough Shortness of breath or difficulty breathing Fatigue Muscle or body aches Headache New loss of taste or smell Sore throat Congestion or runny nose Nausea or vomiting Diarrhea None of the above 4. Have you come into close contact (within 6 feet) with anyone with respiratory illness or a confirmed or suspected case of COVID-19 in the past 14 days? * Yes No 5. If yes, did you wear the required and/or recommended PPE (mask, gloves, etc.) when you were in contact with this person/people? * Yes No N/A 6. Have you travelled or had close contact with anyone who has travelled in the past 14 days? * Yes No If you checked off any of the symptoms in Question 3 and/or answered "Yes" to Question 4 or 6, please call Jamie Tiampo at (415) 999-8299. If you’ve checked off any of the symptoms in question 3 or answered “yes” to question 4 or 6, please call Jamie Tiampo at (415) 999-8299. Thank you!
