COVID-19 pre-production self-screening questionnaire

This questionnaire is to be used by cast, crew, employees and subcontractors prior to the start of filming.

IMPORTANT

The purpose of this questionnaire is to minimise the risk of spreading the COVID virus within the film crew.

It is important to answer the questions accurately.

Some answers may limit your access to the site or require further clarification.

If in doubt, please contact greg@gregmichaelfilm.com for more information.

Name

First Name

Last Name

Phone

1. In the past few days, have you had any of the following symptoms?

- Fever ( 38 C or higher) or feeling of fever (chills) - Cough (new or exacerbation of a chronic cough) - Difficulty breathing or chest pain - Loss of sense of smell or taste without nasal congestion

2. In the past 14 days, have you been in contact with anyone suspected of carrying COVID-19?

3. In the past 14 days, have you been in contact with a confirmed case of COVID-19?

4. In the past 14 days, have you been diagnosed with COVID-19 or do you think you've had it?

5. Do you live with a health care worker?

I certify to the best of my knowledge that this information is accurate.