•

Azure Stages COVID-19 Building Pre-Entry Screening Form

All employees, contractors and visitors must complete this pre-screening questionnaire daily, prior to entering the Azure Stages building. The questionnaire should be completed WITHIN 24 HOURS of your arrival.

After you complete the questionnaire you will receive an on-screen message and an emailed message. As you enter the building you must present the on-screen message or the email message on your cell phone to be allowed in the building.


    In the past 24 hours, have you had two of the following symptoms unrelated to a pre-existing medical condition: *Required
    • Fever (either you felt or measured) or chills
    • Cough
    • Shortness of breath or difficulty breathing
    • Fatigue
    • Unexplained muscle or body aches
    • Unusual headache
    • Loss of taste or smell
    • Sore throat
    • Nasal congestion or runny nose
    • Nausea or vomiting
    • Diarrhea

    YesNo


    Have you had a POSITIVE test for COVID-19 infection within the past ten (10) days, or have you been tested within the past 10 days because of symptoms and are waiting for the results? (required)

    YesNo


    Have you been in close physical contact with someone who tested positive for COVID-19 within the past 14 days? *Close contact: Within six feet of a Covid positive person for a total of 15 minutes or more over a 24-hour period during the 48 hours before the positive person exhibited symptoms or if asymptomatic, 48 hours before the Covid test was administered. (required)

    YesNo


    Have you received a Covid-19 vaccine? (required)

    ReceivedNot Received

    User Acknowledgement


    I acknowledge the terms below.

    I understand the electronic submission of this form effectively serves as my signature and I certify that I have accurately completed the Azure Stages COVID-19 Building Pre-Screening Form and will comply with the outcomes identified above. I understand I may not enter the building if I answered YES to any of the questions above. I acknowledge the terms above and certify that I have completed the COVID-19 screening questions and will comply with the requirements identified.