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COVID-19 Visitor Questionnaire
COVID-19 Visitor Questionnaire
Please contact Markell Currault-Holmes, Human Resources Director, at (504) 593-0625 or mcurrault@deutschkerrigan.com if you have questions. Thank you for assisting us in our efforts to minimize exposure to COVID-19.
Name
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(?)
Date
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(?)
Deutsch Kerrigan Attorney/Staff Name
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(?)
Have you traveled outside of the US in the past 30 days?
Yes
No
If yes, please list the countries visited and the dates of each visit.
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(?)
Have you traveled on an airline or cruiseship in the past 7 days?
Yes
No
Do you currently have any of these symptoms?
Fever over 100.4
Persistent cough
Shortness of breath
Loss of taste or smell
Are you currently waiting on COVID-19 test results?
Yes
No
Have you tested positive for COVID-19 in the past 30 days?
Yes
No
If yes, please give the date of the test result.
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(?)
To the best of your knowledge, have you been in close contact with an individual who has had any of these symptoms: Fever over 100.4, persistent cough, or shortness of breath
Yes
No
If yes, please give date of last contact.
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(?)
To the best of your knowledge, have you been exposed to anyone currently waiting for COVID-19 test results?
Yes
No
If yes, please give the date of last contact.
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(?)
Have you had the COVID vaccine?
Yes, I have had the first of 2 vaccine doses and am currently waiting to have my second dose.
Yes, I have been vaccinated with the one-dose vaccine
Yes, I have had 2 of 2 vaccine doses and have completed the vaccination process
No, I have not begun the process of being vaccinated.
I refuse to answer
I am declining to complete this questionnaire.
Yes
No