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CV-19 Service Provider Daily Waiver
This daily form is for Shear Designs II salon service providers to ensure that during the COVID-19 Pandemic, there are no symptomatic signs of the virus.
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Service Provider's Temperature:
*
Your answer
1. Have you been in contact with anyone that has been diagnosed with COVID-19 virus, and been symptomatic within the past 14 days?
*
Yes
No
Other:
2. Have you had the following symptoms within the past 14 days?
*
Yes
No
Other:
3. Have you had a fever?
*
Yes
No
Other:
4. Have you had a dry cough?
*
Yes
No
Required
5. Have you had a sore throat?
*
Yes
No
Required
6. Have you had shortness of breath?
*
Yes
No
Required
7. Do you have a loss of taste or smell?
*
Yes
No
Required
8. Have you been around anyone exhibiting these symptoms within the past 14 days?
*
Yes
No
Required
Signature (Write Below)
*
Your answer
Date
*
MM
/
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/
YYYY
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