COVID-19 Questionnaire

THE NEW YORK STATE DEPARTMENT OF HEALTH (DOH) RECOMMENDS THAT THIS SCREENING QUESTIONNAIRE BE DONE REMOTELY WHENEVER POSSIBLE.

As part of the phased re-opening for real estate, the DOH released “Interim Guidance for Real Estate Services During the COVID-19 Public Health Emergency”. Within the document, guidance is provided for screening Sellers/Buyers/Landlords/Tenants prior to showing a property in-person. The purpose of the screening questionnaire is to assist the DOH with tracking and tracing COVID-19 exposure and prevent further outbreaks. If you have traveled to New York from another state on or after June 25, 2020, you may be required to quarantine yourself for 14 days. You are being asked to provide your contact information, such that all contacts may be identified, traced, and notified in the event an individual is diagnosed with COVID-19.

Thank you for your co-operation!

COVID-19 HEALTH SCREENING & TRAVEL ADVISORY QUESTIONNAIRE

First

Middle

Last

Date

Phone

Property Address Visiting:

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

Country

Have you knowingly been in close or proximate contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19 ?

Have you tested positive for COVID-19 in the past 14 days?

Have you experienced any symptoms of COVID-19 in the past 14 days?

Have you travelled to/from any other state in the past 14 days?

Please list the states you traveled to/from in the past 14 days

COVID-19 HEALTH SCREENING QUESTIONNAIRE

COVID-19 Questionnaire

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