COVID-19 Risk – Monitor My Health Form – Infant Basics and Toddler Training

To be filled out by 9am the morning of the in-home consult or CPR and Choking Course by client/guardian and Infant Basics and Toddler Training’s consultant.

I confirm that I and the others who will be present for the in-home consult or CPR and Choking Course am not presenting any of the following symptoms of COVID-19 listed below: Fever (>99.9F), New or Changing cough, Dry cough, Shortness of breath, Change in smell or taste, Vomiting, Diarrhea (loose stools that occur more frequently than usual. At least 5 episodes within a 24 hour period.). (initial below)(required)

I verify that I and anyone who will be present have not traveled outside the United States within the past 14 days. (initial below)(required)

I verify that I and anyone who will be present have not traveled domestically within the United States by commercial airline, bus or train within the past 7 days. (initial below)(required)

For the in-home consult or CPR and Choking Course, I and everyone who will be present will follow Infant Basics and Toddler Training's strict guidelines in line with the CDC: wear a mask when we are not able to be 6 feet away from each other, wash hands often, practice social distancing by maintaining 6 feet away from each other when appropriate, and fill out the monitor my health form the morning of the in-home consult or CPR and Choking Course. (initial below)(required)

I verify that I and anyone who will be present for the in-home consult or CPR and Choking Course have not tested positive for COVID-19 in the past 21 days. If you or someone else who will be present has tested positive in the past 60 days, please write date below. (initial below)(required)

*Client/Guardian eSiganture Below*(required)

*Infant Basics and Toddler Training Consultant eSiganture Below*

Date(required)

Email(required)

Share this:

Like this: