eWaiverPro

EMPLOYER / COMPANY COVID SCREENING EXAMPLE

To keep our staff, employees and customers at this locaton safe during the COVID-19 pandemic, we require anyone entering this lcoation to answer to the following questions.

Have you tested positive for COVID-19 in the last 7 days?

Are you vaccinated?

Are you waiting for a COVID–19 test or a test result?

Have you experienced any flu-like symptoms in the last week?

Have you ever tested positive for COVID-19?

I have answered these questions honestly and to the best of my ability.

If you answered yes to any of these questions, please provide details in the notes box below your name and notify our staff.

Participant’s INFORMATION

First Name

Last Name

Notes

MINOR

First Name

Last Name

Date of Birth (mm/dd/yyyy)

MINOR

First Name

Last Name

Date of Birth (mm/dd/yyyy)

MINOR

First Name

Last Name

Date of Birth (mm/dd/yyyy)

MINOR

First Name

Last Name

Date of Birth (mm/dd/yyyy)

MINOR

First Name

Last Name

Date of Birth (mm/dd/yyyy)

MINOR

First Name

Last Name

Date of Birth (mm/dd/yyyy)

MINOR

First Name

Last Name

Date of Birth (mm/dd/yyyy)

MINOR

First Name

Last Name

Date of Birth (mm/dd/yyyy)

MINOR

First Name

Last Name

Date of Birth (mm/dd/yyyy)

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EMPLOYER / COMPANY COVID SCREENING EXAMPLE

Participant’s INFORMATION

Use your finger or stylus to sign your name inside box

USE YOUR FINGER OR STYLUS TO INITIAL INSIDE BOX

Use your finger or stylus to
sign your name inside box

USE YOUR FINGER OR STYLUS
TO INITIAL INSIDE BOX