sur·vey

/sərˈvā/ • verb
to query (someone) in order to collect data for the analysis of some aspect of a group or area.

COVID-19 Post Event Survey

Contractor’s Name*
First Last
Email Address*
Phone Number*
Today's Date*
MM slash DD slash YYYY
Event Name*
Event Date*
MM slash DD slash YYYY
Since working the event with CLEMCO.AV, have you experienced any symptoms associated with COVID-19: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea?*
- Yes
- No
Have you been tested for COVID-19 since leaving the job site?*
- Yes
- No
If tested, did you test positive for COVID-19?**
- Yes
- No
- N/A
Enter your initials below to acknowledge the following statements: I understand this survey is 100% confidential and in the event that the survey does suggest that someone may have symptoms of, or tested positive for, COVID-19, an email will be sent to those individuals who may have be affected with a list of recommended next steps.*

*** Any personal information submitted will be secured and only used for it’s intended purpose.