Questionnaire

EMPLOYEE COVID-19 SCREENING QUESTIONNAIRE

The safety of our employees is our overriding priority. As the coronavirus (COVID-19) pandemic continues, we are monitoring the situation closely and following the guidance from the Centers for Disease Control and Prevention and local health authorities. In order to prevent the spread of the coronavirus and reduce the potential risk of exposure to our colleagues, we are asking everyone to complete and submit this questionnaire prior to entering the worksite. Please do not enter the worksite if you answered "Yes" to any of the questions below.

Please respond to each of the following questions truthfully and to the best of your ability. Your participation is important to help us take precautionary measures to protect you and your co-workers.

* Required

Name*

In the past 14 days, have you been in close proximity to anyone who was experiencing any of the above symptoms or has experienced any of the above symptoms since your contact?*
Yes No

In the past 14 days, have you been in close proximity to anyone who has tested positive for COVID-19?*
Yes No

In the past 14 days, have you been tested for COVID-19 and are waiting to receive test results?*
Yes No

I hereby certify that the responses provided above are true and accurate to the best of my knowledge.

Signature/Full Name*	Date*

View Stats

Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms?*
Fever (100.4° F/37.8° C or greater as measured by an oral thermometer)	Yes No
Cough	Yes No
Shortness of breath of difficulty breathing	Yes No
Sore throat	Yes No
New loss of taste or smell	Yes No
Chills	Yes No
Head or muscle aches	Yes No
Nausea, diarrhea, vomiting	Yes No

Wildenstein & Co. Inc.

689 Fifth Avenue

New York, NY 10022

212-879-0500

info@wildenstein.com