To attend an indoor euthanasia, please read the following, then “sign” and date at the the bottom before you send the form.
Note that up to two attendees may be present, and both need to be listed.
I do declare that:
I am not currently diagnosed with COVID-19
To the best of my knowledge, I have not (within the last 14 days) been in close contact with anyone diagnosed with (or suspected to have) COVID-19 (where ‘suspected to have’ means the person is exhibiting the principal symptoms of COVID, as described below, and ‘close contact’ is being within 6 feet for a cumulative 15 minutes or longer [within a given 24 hour period] OR providing care at home to someone who is sick with COVID-19 OR hugging/kissing an infected person OR sharing eating/drinking utensils OR the other person sneezed, coughed, or otherwise got respiratory droplets on you). Note that this ‘close contact’ period begins 2 days before symptoms developed (for exposure to symptomatic individuals) or 2 days before the COVID-19-positive specimen was taken (for exposure to asymptomatic individuals) – whichever period came first.
In the last 10 days, I’ve simultaneously experienced no more than one of these symptoms (doesn’t include symptoms due to known, non-COVID medical/physical condition): chills, muscle/body aches, headache, sore throat, fatigue (not otherwise explained by another known cause), diarrhea, nausea or vomiting, abdominal pain, congestion or runny nose.
During the last 10 days, I have not experienced any of the following symptoms (not including symptoms due to a known, non-COVID medical or physical condition): fever(≥100.4 oF), cough (excluding chronic cough due to a known medical reason other than COVID-19), shortness of breath or difficulty breathing, loss of taste or smell.
By completing the information below and submitting this form, I agree that the above statements are true.