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COVID-19 Questionnaire: Image


To be completed by all clients before proceeding with in-home consultations or installations.

Please know if you have answered yes to any of the following questions about you, we are not permitted to proceed with either an in-home consultation or installation.

By submitting this questionnaire, I agree to the following:

1. If I experience any symptoms of fever or signs of a fever such as chills sweats muscle aches and light-headedness cough headache sore throat runny nose or have been in close contact with anyone who has been suspected or confirmed to have covid-19 or have been in contact with anyone who has symptoms of a fever or signs of a fever cough headache sore throat runny nose after signing or submitting this questionnaire I will advise Nicole Brigham immediately and will not proceed with in-home work with Brigham Interiors until cleared to do so.

2. I will submit to any reasonable and additional screening for covid-19 required by Brigham Interiors which may include but not limited to taking my temperature which additionally screening may result in my being refused in-home work;

3. I will report any symptoms as listed while working with Nicole Brigham immediately;

4. The answers to these six questions above are true; and

5. I consent the disclosure of the confidential information contained in this COVID-19 screening questionnaire to Nicole Brigham of Brigham Interiors for the purpose of assessing whether or not I have covid-19 symptoms as well as confirming there has been any compliance with this covid-19 screening questionnaire.

*Physical contact is defined as a person who is provided care for the individual including healthcare workers family members or other caregivers or who had other similar close physical contact with a person with a consistent and appropriate use of personal protective equipment or who lived with or otherwise had closed pro long contact within two meters with the person while they were infectious or had direct contact with the infectious bodily fluids of the person example was coughed or sneezed on while not wearing recommended personal protective equipment.

**Anyone who has tested positive for covid-19 can only return to the workplace if they've provided satisfactory evidence that they have recovered from covid-19.

Do you have any of the following symptoms?:
Do you have any new or unusual symptoms?
Have you traveled outside of New Brunswick in the last 14 days?
Have you had close contact within the last 14 days of a confirmed case of covid-19?
Have you had physical contact with a person being tested for covid-19 within the last 14 days?
Have you had a positive test for covid-19 or are you awaiting results from covid-19 testing?

Thanks for submitting!

COVID-19 Questionnaire: Feedback Form
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