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

Date

Deutsch Kerrigan Attorney/Staff Name

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.

Do you currently have any of these symptoms?

Fever over 100.4
Persistent cough
Shortness of breath

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.

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.

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.

Have you traveled on an airline or cruiseship in the past 7 days?

Yes
No

I am declining to complete this questionnaire.

Yes
No