HCC CORONAVIRUS

COVID-19 FORM

FOOD PANTRY VOLUNTEERS – FILL OUT BEFORE ARRIVING AT THE PANTRY.
In person service: FILL OUT BEFORE ARRIVING AT THE SERVICE

Please complete the form below

Name

First Name

Last Name

Phone

I am

In the past 10 DAYS have you tested positive for Covid-19 virus?

Yes

Do you currently have any of the following symptoms: fever, cough, shortness of breath, sore throat, or any other common covid-19 virus symptoms?

Yes

In the past 14 DAYS have you had close personal contact (within 6 FEET, or sharing the same office or living space) with someone who has tested positive for Covid-19 virus and INFORMED YOU of their diagnosis?

Yes

In the past 14 days have you traveled to any of the states or countries currently on the New York State's and US travel advisory and have you been advised by authorities to self-quarantine?

Yes

IF YOU ANSWERED YES TO EITHER OF THE QUESTIONS, DO NOT ENTER COMMON AREAS OF THE BUILDING, WORK IN OFFICES SHARED BY MORE THAN 1 PERSON, OR HANDLE FOOD PANTRY ITEMS. FOLLOW CDC’s Covid-19 prevention and quarantine protocols.

I acknowledge that I understand and will comply with the policy

Acknowledgement

Health Form

FOOD PANTRY VOLUNTEERS – FILL OUT BEFORE ARRIVING AT THE PANTRY.

In person service: FILL OUT BEFORE ARRIVING AT THE SERVICE

Please complete the form below

EVENTS

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Location