COVID Disclosure Formulaire

Everything in this questionnaire is optional. Choose to disclose anything you think it will make the people you are meeting more comfortable.

No information is sent out. Tis is an off-line form. Once you are finished, you can get a summary of your answers to send out (that requires to run some local JavaScript) or you can print to PDF the completed questionnaire.

  1. Do you think the SARS-CoV-2 ("coronavirus" or "COVID") is a hoax (i.e., there is no virus)?


    (If yes, no need to fill up the rest! Thanks for the heads up.)

  2. How much do you care about not catching the SARS-CoV-2 virus?





  3. Are there people in your household you care not to get infected?


    If yes, who? (You can disclose this for people to share your concern for your loved one and better understand your need for them to wear face masks, etc). I worry about my:

  4. How many people are in your household (including yourself)?




  5. How many people would you estimate are in the "social bubble" of your household (people seen by somebody in your household, including yourself, at least once a month)?





  6. Is there anybody in your household (including yourself) that works outside your home?


  7. Is there any person in your household (including yourself) that attends in-person classes (or children in daycare)?


  8. If you meet people socially, do you wear a face mask?




  9. If you meet people socially, do you expect others to wear a face mask?




  10. How often does any person in your household (including yourself) takes mass transit (choose the answer for the most frequent traveler)?




  11. Have anybody in your household (including yourself) been in an airplane in the last two weeks?


Summary


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