Marna Bales January 25, 2022 COVID-19 WELLNESS CHECKLIST Marna Bales January 25, 2022 Date Entering Building * MM DD YYYY Name * First Name Last Name Email * Phone * (###) ### #### Fever * Do you have a fever (temperature over 100.30F) without having taken any fever reducing medications? Yes No Loss of Smell or Taste? * Yes No Muscle Aches? * Yes No Sore Throat? * Yes No Cough? * Yes No Shortness of Breath? * Yes No Chills? * Yes No Headache? * Yes No Have you experienced any gastrointestinal symptoms such as nausea/vomiting, diarrhea, loss of appetite? * Yes No Have you, or anyone you have been in close contact with been diagnosed with COVID-19, or been placed on quarantine for possible contact with COVID-19? * Yes No Have you been asked to self-isolate or quarantine by a medical professional or a local public health official? * Yes No Have You Been Fully Vaccinated? * Yes No Boosted Final Vaccination or Booster Date (if applicable) If you have been vaccinated or boosted, please note the date of your final vaccination below. MM DD YYYY I have reviewed and agree to abide by Red Amp's COVID-19 Protocol. * By checking this box, I acknowledge I have read all of Red Amp Audio's COVID-19 Protocol and agree to abide by the guidelines. Thank you! Please Review and Answer Each Question ON THE DAY you will be entering the studioIf you are experiencing any of these symptoms, please do not enter the building and contact your health provider immediately for guidance.
