COVID-19 Self Screening Questionnaire

You must answer “NO” to all the questions in this questionnaire in order to enter our physical location. If you answer “YES” to any of the questions, please DO NOT enter the Hill Estate.

If you experience any symptoms or answer “YES” to any of these questions, you should immediately contact your health care professional for recommended next steps AND STAY AT HOME.

1) Have you had any of the following symptoms in the last 24 hours? *

Yes

No

Cough

Shortness of breath of difficulty breathing

OR at least TWO of the following symptoms in the last 24 hours: *

Yes

No

Fever (usually 100.4 or higher)

Chills

Repeated shaking with chills

Muscle pain

Headache

Sore throat

New loss of taste or smell

If you answered “Yes” to question one, please DO NOT come to the Hill Estate. You should:

Self- quarantine for at least 10 days from the date on which you first experienced any of the above symptoms ; AND
Wait until you have had no fever for at least 3 days (without the use of fever-reducing medication) AND
Improved respiratory symptoms (no cough, shortness of breath)

2) In the last 14 days have you: *

Yes

No

Been in contact with someone who was diagnosed with COVID-19?

Been in close contact with someone who had COVID-19 symptoms ?

Traveled internationally or taken a cruise

I agree to indemnify, defend, and hold harmless the Hill Estate from and against any and all costs, expenses, damages, claims, lawsuits, judgments, losses, and/or liabilities (including attorney fees) arising directly or indirectly from or related to any and all claims made by or against any of the Released Parties due to bodily injury, death, loss of use, monetary loss, or any other injury from or related to my use of the Hill Estate facilities, tools, equipment, or materials, whether caused by the negligence of the Released Parties or otherwise specifically related to COVID-19 or any other event that may occur.

If you answered “Yes” to any part of question two, please DO NOT to the Hill Estate. You should selfquarantine for at least 14 days.

I certify to the best of my knowledge; this information is accurate.

Signature *

Clear

Name *

First Name Last Name

Date *

Date