Staff Health Form

Staff Information
Staff's Name
Emergency Contact Information
2nd Emergency Contact Name OTHER than listed above:
Health Information

Status message

AT HOME HEALTH SELF ASSESSMENT:
The following questions you will need to ask yourself before coming to work.

  1.  Is my temperature above 100.4 degree F?
  2. Has anyone in the household had contact with a confirmed COVID case in past 10 days without taking CDC procautions and proper PPE?
  3. Have I had a cough, fever, chills, shortness of breath, body aches, congestion, runny nose, unusual headaches, fatigue, cough, sore throat in the last 48 hours?
  4. Have I had new loss of taste or small in the last 48 hours?
  5. Have I vomited or have felt nausea in the last 48 hours?
  6. Has anyone in my family been to a hotspot or state in the past 10 days?
  7. Has anyone in your household had COVID-19 positive test or have suspected Covid-19 in the last 14 days?
  8. Am I or anyone I have been in contact with, awaiting COVID test results?
If you respond yes to any of these questions please contact an administrator

Please ensure you have washed you hands thoroughly before leaving home and upon returning home. Please wash your hands as soon as you arrive to the building and before you leave the building.

Your temperature will be taken upon arrival to work. 

If yes, have you discussed your work with your Healthcare provider.
Immunization Information

Status message

If you are going to a hot spot (10% positivity rate) and will be visiting beaches, going out to eat indoors OR outdoors, going to a hotel/resort, visiting crowded areas (such as a boardwalk), visiting amusement parks or water parks, or doing indoor activities you will be required to get tested or self-quarantine for 14 days.

If you will be within 6 feet for longer than 5 minutes with someone who has a suspected or confirmed case of Covid (this includes anyone you do not know) without taking proper precautions like wearing a mask and frequently washing your hands you will need to be tested or self-quarantine for 14 days before returning to the gym.
 

If you go to ANY water park, amusement park, carnival, fair, or festival you will be required to get tested or self-quarantine for 14 days.
 

If you are going to a location that is NOT a hot spot but will be visiting beaches, going out to eat inside restaurants, going to a hotel/resort, visiting crowded areas (such as a boardwalk), visiting amusement parks or water parks, or doing indoor activities, you must wear a mask, stay 6 feet apart at all times from others, and practice frequent hand washing. If you cannot ensure these safety precautions are taken at all times, you will need to get tested or self-quarantine for 14 days.
 

If you are flying, you should take hand sanitizer and frequently use.  Practice extreme caution.  If your plane is crowded and you can not maintain 6 ft from others (except your bubble of people) you will need to get tested or self-quarantine for 14 days
 

Please understand that this is a fluid situation and things are changing daily. We are doing our best to protect everyone and to keep the gym open. Please  send us your vacation plans and details so we can keep a record.


Please remember this includes day trips and other trips. Be sure to include as much detail as possible (where are you going and staying, are you going to a beach and if so which beach, are you going out to eat, what measures are you taking to prevent covid,etc).  This is to keep everyone safe.

I understand that the coaches, administrators and owners as well as everyone at the gym will make a strong effort to maintain social distancing; but, that there will be times when incidental contact and less than prescribed physical distancing will occur. I also understand that the new procedures and protocols in place by Harford Gymnastics is to help mitigate the risks of Covid-19 and other germs. I know that even with increased sanitation and enhanced hygiene protocol, it is impossible to provide a completely sterile environment so the risk of Covid-19 exposure and other viruses may exist and I accept that risk.
I have been educated in the new enhanced sanitization procedures and fully understand them. I agree to follow all the sanitization and germ mitigating protocol.
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