Name *

First Name

Last Name

Phone Number

(###)

###

####

Permission to enter in your absence *

Do you give maintenance staff permission to complete your requested service order in your absence?

Yes

No

COVID-19 Exposure Questions *

Within the past 14 days, have you or anyone in the household experienced any of the following: ▪ Suffered from a fever, cough, sore throat, difficulty breathing, or other condition commonly associated with COVID-19? ▪ Tested for COVID-19? ▪ Hospitalized [for any reason]? ▪ Traveled excluding local trips? ▪ Attended a social event? ▪ Been exposed to someone with, or suspected to have, COVID-19?

Yes

No