Coronavirus (Covid-19) Prevention and Business Continuity

As the concerns regarding Coronavirus continue to grow, Recruit and Field would like to take this opportunity to protect our team, researchers, partners, and respondents.

Because we want everyone to be and stay healthy, we have a few questions to ask each individual. Please check your answers.

Name

First Name

Last Name

Q1. In the last 14 days, have you traveled to an area where there is widespread, sustained, or community transmission of COVID-19, the novel coronavirus?

Some examples of these areas are: o Italy - Lombardy or Veneto o South Korea – all areas o People’s Republic of China (this does not include Hong Kong, Macau, or the island of Taiwan) o Iran – all areas o United States – Seattle, WA, Santa Clara County, CA Before answering, please refer to the following link for up to date list of areas affected: https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html

Yes

Q2. In the last 14 days, have you had cough, fever, or shortness of breath?

Q3. In the last 14 days, have you been in close contact with anyone either at risk, or infected with COVID-19?

Q4. Have you been tested for COVID-19?

By printing your full name below you acknowledge that you have truthfully answered all questions on this form

Print Full Name

Print Initials

Date

YYYY