Full Legal Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Have you experienced any of the following symptoms in the past 48 hours: *

• Fever higher than 100.4 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

Within the past 14 days, have you been in close physical contact (6 feet or closer for at least 15 minutes) with a person who is known to have laboratory-confirmed a COVID-19 case or with anyone who has any symptoms consistent with COVID-19? *

YES

NO

Have you been, or are you isolating or quarantining because you may have been exposed to a person with COVID-19 or are worried that you may be sick with COVID-19? *

YES

NO

Within the last 10 days, have you been diagnosed with COVID-19 or had a test confirming you have the virus? * *

YES

NO

Do you consent to having your temperature checked, wearing PPE, washing your hands and social distancing during the production, including during travel and after hours? *

YES

NO

By clicking 'Yes' below you agree to alert the production company if you test positive for Covid-19 before, during or within 14 days of wrap? *

YES