info@shadowboxdm.com
516.605.1090
1 Enterprise Place, Unit D, Hicksville, NY 11801
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COVID-19 Screening
Home
What We Do
Systems Integration
Production Design
Live Event Production
Portfolio
Contact
COVID-19 Screening
Crew Daily Covid-19 Screening Questionnaire
Please complete this form the day before you are scheduled to work. All fields are required.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email Address
*
Best email to reach you. A confirmation copy of this form will be sent to this address.
Cell Phone
*
Cell phone or best phone number to reach you.
Event Name
*
Name of the "Event" you are working. This is on the Call Confirmation Sheet PDF you were emailed.
Call Title
*
Can also found on Call Confirmation Sheet. If working multiple calls on one day, please list all calls.
Call Date
*
This is the date that you are working the above call or calls.
Project Manager
*
John McGovern
Joe Ondrek
Charlie Ondrek
Bob Dziemian
Can be found on the Call Confirmation Sheet PDF.
To your knowledge, have you been in close contact in the past 14 days with anyone who has tested positive for COVID-19 or had symptoms of COVID-19?
*
Yes
No
Have you tested positive for COVID-19 in the past 14 days?
*
Yes
No
Have you experienced any of the following symptoms of COVID-19 in the past 14 days?
*
Fever over 100 degrees
Shortness of breath or difficulty breathing
Chills and/or muscle ache
Dry cough
Sore throat
Loss of taste or smell
Blueish face or lips
No - None of the above
Have you or anyone with whom you have been in close contact in the past 14 days, recently returned from international travel, or from a restricted state to New York State?
*
Yes
No
Submit
