COVID Questionnaire - Golden State Restaurant Group

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About
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COVID Questionnaire

The health and wellness of
our team and guests is
our highest priority.

COVID Questionnaire

Please answer the following questions for the Benefit Department.

Step 1 of 2

50%

Name*
First Last
Best Contact Email*
Best Contact Phone*
Restaurant*
Acknowledgement
- I agree
I certify that the information submitted is true and correct to the best of my knowledge.
Signature*
Have you been vaccinated?*
- Yes
- No
- Decline to answer
Has it been more than 14 days since your last vaccination?*
- Yes
- No
- Decline to answer
In the last 14 days you have...*
- been exposed to someone who tested positive for Coronavirus?
- been experiencing flu-like symptoms?
- neither exposed nor experiencing sympyoms

Exposure Questions
Does the individual who tested positive live inside of your household or outside of your household?*
- Inside of my household
- Outside of my household
How many days has it been since the last date of exposure?
Have you experienced symptoms in the last 3 days (72 hours)?
- Yes
- No
Are you currently taking any fever reducing medication?*
- Yes
- No
Have you gone at least 24 hours without a fever?*
- Yes
- No
Have you completed the recommended 14 day quarantine?*
- Yes
- No
Has everyone in your household been symptom free for more than 3 days (72 hours) and/or tested negative for Coronavirus?*
- Yes
- No
Symptom Questions
Have you taken a Coronavirus test?*
- Yes
- No
Test Date*
MM slash DD slash YYYY
Were results positive or negative?*
- Positive
- Negative
Have you completed the recommended quarantine?*
- Yes
- No
Have you experienced symptoms in the last 3 days (72 hours)?*
- Yes
- No
Are you currently taking any fever reducing medication?*
- Yes
- No
Have you gone at least 24 hours without a fever?*
- Yes
- No
Is anyone else in your household experiencing flu-like symptoms or tested positive for Coronavirus?*
- Yes
- No

Keeping your personal information safe is important to us, please see the CCPA if you have any questions.

We are looking for hard working, enthusiastic individuals!

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