COVID-19 Pre Site Questionaire

Company Name *

Service Address

City

State/Province

Zip/Postal

Service Request *

What type of work do you need to be done on-site?

Project *

Please provide a detailed description about the on-site work you are requesting

Requested Date of Service *

Essential Business

Yes

No

Are you considered an essential business based on local laws?

Submitted By *

Email *

Phone

Documented Safety Protocol *

Do you have COVID-19 Safety Documentation?

Please provide the size of the area we will be working in

(Approximate Sq. ft.)

How many people will be present at the time of service?

(Not including our technician)

Can services be completed remotely?

Physical Distancing Policy

Yes

No

Can a minimum distance of 6' be maintained during on-site service at all times? Are there site resources to monitor and enforce?

Face Mask Required

Yes

No

Are all on-site personnel required to wear facial protection? Is there an on-site resource to monitor and enforce?

Gloves Required?

Yes

No

Are all on-site personnel required to wear gloves?

Cleaning *

In the areas where Z Systems' services are to be performed, how are the surfaces being cleaned and sanitized?