COVID Form

NJ COVID compliance form for The Basic Basement Co., Totally Plumbing, and guests. This form must be completed daily in order to comply with company and State of New Jersey regulations.

Name*
First Last
Date*
MM slash DD slash YYYY
Question 1*
In the past 14 days, have you had close contact as defined as: a) Being within approximately 6 feet of a COVID-19 case for a prolonged period of time (greater than or equal to 10 minutes); OR b) Direct contact with infectious secretions from a patient with COVID-19. Infectious secretions may include sputum, serum, blood, and respiratory droplets (e.g., being coughed or sneezed on) with an individual diagnosed with COVID-19?
- Yes
- No
Question 2*
Within the last 10 days have you been diagnosed with COVID-19, had a test confirming you have the virus, or been advised to self-isolate or quarantine by your doctor or a public health official?
- Yes
- No
Question 3*
Have you had any one or more of the following symptoms today or within the past 24 hours, which is not new or not explained by another reason?: Fever, chills, cough, shortness of breath, sore throat, fatigue, headache, muscle/body aches, runny nose/congestion, new loss of taste or smell, or nausea, vomiting or diarrhea?
- Yes
- No
Signature*