PRODUCER

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Please fill in truthfully to ensure the safety of everyone involved in filming.

Name

Surname

Email

Office

Birth date

I have already been diagnosed with COVID-19.

If yes, how long?

I had contact with someone diagnosed with COVID-19 less than 15 days ago.

I was on a set with a confirmed case of Covid-19 in the last 15 days

I have traveled in the last 15 days.

If yes, where?

I have had the following symptoms in the last 15 days:

Fever

Cough

Sore throat

Shortness of breathe

Headache

coryza

inexplicable tiredness

Conjunctivitis

vomiting

Diarrhea

Loss of smell or taste

What is the date and type of your last covid test?

Have you ever been vaccinated? How many doses have you been given?

I declare that all the above information is accurate and true.

Date

Signature

Thanks! :)

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