Covid-19 Screening- Fire Dept visitors

2. COVID-19 Screening Form- to be completed by Visitors to City of Fremont, Fire Department.
   Please respond to all questions. Fremont Fire Department reserves the right to deny Fire Department building "access" to anyone who answers "yes" to any of the questions listed below.

   Please respond to all questions. Fremont Fire Department reserves the right to deny Fire Department building "access" to anyone who answers "yes" to any of the questions listed below.

4. 1) Have you displayed symptoms of COVID-19 (fever, chills, cough, tiredness, body aches/pains, shortness of breath, nausea with vomiting, diarrhea, sore throat, night sweats, headaches, confusion, loss of taste/smell) in the last 24 hours? *

   1. Yes

   1. No

6. 2) Has a member of your household displayed any COVID-19 symptoms or tested positive n the last two weeks?*

   1. Yes

   1. No

8. 3) Have you had close contact with an individual who has displayed COVID-19 symptoms or tested positive for COVID-19 in the last two weeks? Close contact is considered as closer than six feet for a prolonged period of time and/or being sneezed/coughed on.*

   1. Yes

   1. No

10. Visitor's First and Last Name*

11. Business / Organization Name

13. Contact Phone (for visitor)*

14. Contact Email (for visitor)*

16. Fire Department Staff (staff you are working with on this visit/request/project)*
    -- Select One --Angeles Frohnen (Hazardous Materials)Cindy Monges (Hazardous Materials)Cristina Pena(Hazardous Materials)Erika Michelotti (Hazardous Materials)Paul Ferreira (Hazardous Materials)Bruce Chase (Prevention)Aaron Garcia (Prevention)Chad Anderson (Prevention)Matthew Wilson (Prevention)Lisa Zyskowski (Prevention)Other Staff (Fire Administration)

17. Date/Time of Visit*
    Date/Time of Visit

    Date/Time of Visit

19. Purpose of visit (brief description)*

21. I hereby certify that the responses above are true and correct to the best of my knowledge.*

    1. Yes

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23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit Submit and Print

* indicates a required field