Covid-19 Risk Assessment Questionnaire

As you fill out the forms, some items will be required. These will be marked,*, to indicate a required field. You will not be able to progress to the next step without this information.

Entegrus has taken additional safety precautions when entering a customer home. These include wearing face masks, safety glasses, gloves, boot covers and will practice social distancing at all times.

In response to the COVID-19 pandemic, and to ensure the health and safety of all customers and staff, we ask that you please complete the following consent form prior to any in-person interactions. Also note: This form must be completed within 48 hours of the appointment you're scheduling.

Appointment Information:

Contact Information



Where can Entegrus reach you with further questions about your questionnaire?

Form Submission Date: 01/22/2021

Screening Questionnaire

  
  
  
  
  
  
  
  

NOTE: We cannot risk the health of our employees. If you answer yes to any of the questions from 4 - 7, Entegrus representatives will not be permitted to enter the customer’s premises.

By clicking 'Submit':

I acknowledge that I understand the risks associated with having someone from outside of my family enter my home and agree that I am willing to accept these risks as a condition of agreeing to Entegrus entering my home.

I confirm that I have been informed of the safety procedures put in place to avoid the spread of COVID-19 by Entegrus and that any questions that I had regarding the provision of the Services during the COVID 19 pandemic have been answered to my satisfaction.

I confirm that I have completed this questionnaire to the best of my knowledge and in good faith. If after services are performed and either the Entegrus Representative or the customer later test positive for COVID-19, both are obligated to inform each other.

I understand and acknowledge that it is my right to postpone any stage of these services & I agree that should I wish to postpone I will communicate this with Entegrus as soon as possible to ensure the efficient use of resources.

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