ALLIANCE HEALTH SCREENING
FOR SERVICE STAFF GOING INTO HOMES AND BUYERS VISITING DÉCOR CENTRE

Effectively immediately, Alliance is requiring all homeowners to fill out this health screening form and submit it before any of our service staff enter their homes, or before homeowners visit our décor centre. Alliance will hold all personal health information in confidence. Until this form is completed and submitted, entry into the décor centre and work on the homes will be withheld.

While service personnel are in the home, homeowners must practice social distancing and remain in a different room from where they are working. In the case of the décor centre, masks, hand-washing/sanitizing and social distancing are required.

Please have the head of the household fill out this form on behalf of all residents.

Name(s):
Email:
Community/Site:
Address or Lot #:
Phone:

1. Are any of the occupants of the household experiencing any of these COVID-19-related symptoms?

  • Fever (37.8 degrees C, 100 degrees F or higher)
  • Chills
  • New, worsening or barking (croup-like) cough
  • Shortness of breath
  • Severe and constant chest pain
  • Sore throat
  • Difficulty swallowing
  • Headache (more severe than normal)
  • Loss of consciousness
  • Mental and/or logistical confusion
  • Extreme fatigue inconsistent with lifestyle
  • Congestion via runny or stuffy nose (not caused by allergies)
  • Loss of the sense of smell and/or taste
  • Digestive problems such as nausea, diarrhea, vomiting, stomach cramps
  • Loss of balance causing falling more than usual
  • Pink Eye

No
Yes

2. Thinking of the above symptoms, have any home occupants experienced any of these within the past 14 days?
No
Yes

3. Are you or are any occupants of the home currently waiting for the results of a COVID-19 test?
No
Yes

4. Have you returned recently from international travel?
No
Yes

5. Have any other occupants of the home returned recently from international travel?
No
Yes

6. Has a health care professional asked you to self-isolate for 14 days and self-isolation not completed?
No
Yes

7. Has a health care professional asked anyone else living in the home to self-isolate for 14 days and self-isolation not completed?
No
Yes

8. Thinking of yourself and everyone else living in the home, have any of you experienced any of the following:

  • In-person visit with a confirmed COVID-19 case
  • In-person visit with an individual who is awaiting test results for COVID-19
  • Living in the same household with someone who has returned recently from international travel or who has been required to self-isolate
  • Living in the same household with someone who has COVID-19 symptoms as outlined in #1

No
Yes

Head of Household Declaration

All residents of this home have read and agreed to comply with the health and safety requirements outlined above such as social distancing, mask-wearing and hygiene procedures whenever Alliance staff enter the home or the homeowners enter the Alliance décor centre.


* Required