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Covid-19 Waiver

Please answer the following questions

COVID-19 Waiver

Have you been asked to self-isolate or quarantine by a doctor or a local public health official in the last 14 days? *

Yes

No

OtherOther

Have you experienced any cold or flu-like symptoms in the last 14 days(fever, cough, shortness of breath or other respiratory problem)? *

Yes

No

OtherOther

Have you had close contact with or cared for someone diagnosed with COVID-19, or someone exhibiting cold or flu-like symptoms within the last 14 days? *

Yes

No

OtherOther

Have you been tested for COVID-19? What type of test did you have? When were you tested? What was the result? *

Yes

No

If you answered Yes, please explainIf you answered Yes, please explain

Have you been vaccinated? *

Yes

No

If you answered Yes, please provide date of second vaccine:If you answered Yes, please provide date of second vaccine:

I would rather not say

You understand that close contact with people increases the risk of infection from COVID-19. By signing this form, you acknowledge that you are aware of the risks involved and give consent to The Chicago Stress Relief Center, Inc. to receive services. *

Yes

No

You understand that your name and contact information might be shared with the state health department in the event that a client or staff at The Chicago Stress Relief Center, Inc. tests positive for COVID-19. Your contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department. *

Yes

No

Date

Email Address *

Participant First Name *

Participant Last Name *

Date of Birth *

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