COVID-19 Policy Acknowledgement, Health Attestation & Proof of Vaccination (required for facility entry)

FCTV remains committed to providing a safe and welcoming environment and has instituted guidelines for anyone entering Falmouth Community Television (FCTV) facilities.

Health and safety protocols have been adopted from best practices of the film and television industry, currently in use by production studios here in Massachusetts and adapted as resources allow.

UPDATED October 18, 2021 - anyone entering our facilities or using the FCTV production vehicle must be fully vaccinated against COVID-19, provide one-time proof of vaccination (see below), and fill out and sign this form.

This form must be submitted a minimum of two but no more than 24 hours prior to entry.

First Name *

Last Name *

Email *

Phone Number *

Please Read

1 *

I understand that to enter the FCTV facility I must be FULLY vaccinated against COVID-19 (* Fully vaccinated occurs two weeks after receiving the second dose of the two-dose vaccine (Moderna or Pfizer) or two weeks after the single-dose (J & J) vaccine and any booster shots as recommended by the CDC when eligible).*Subject to change per CDC requirement.

2 *

I understand that to enter the FCTV facility I must be free from COVID-19 symptoms. If during your visit or subsequent to your visit, any symptoms appear, I agree to immediately notify FCTV’s Executive Director or Director of Operations.

3 *

I understand that I must always wear a CDC compliant face mask while at FCTV. Masks must be clean, free of rips or tears, and worn properly (covering the nose and mouth). Gaiter-type face masks are not permitted.

4 *

I have not had close contact with any individual diagnosed with COVID-19 in the last 14 days.

5 *

I understand that FCTV has adopted enhanced cleaning procedures and I will comply with all cleaning and disinfecting any equipment or work area I used as requested by staff.

6 *

I will immediately notify the FCTV Executive Director or Director of Operations if I become aware of any person with whom I have had contact exhibits any COVID-19 symptoms, is advised to self-isolate, quarantine, or has tested positive, or is presumed positive for COVID-19.

7 *

I understand that while at FCTV I will be in contact with staff and other members of the public who are also at risk of community exposure. I understand that no list of restrictions, guidelines, or practices will remove 100% of the risk of exposure to COVID-19 as the virus can be transmitted by persons who are asymptomatic and before some people show signs of infection. I understand that I play a crucial role in keeping everyone at FCTV safe and reducing the risk of exposure by following the practices outlined herein.

COVID-19 Vaccination Status *

Please indicate your level of COVID-19 vaccination.

If fully vaccinated, please indicate the date.

Month

Day

Year

(Fully vaccinated occurs two weeks after receiving the second dose of the two-dose vaccine (Moderna or Pfizer) or two weeks after the single-dose (J & J) vaccine or upon receiving the booster shot as recommended by the CDC when eligible.) *Term 'Fully' is subject to change based on CDC guidance.

To upload your proof of vaccination securely, please click here or plan to arrive at FCTV ten minutes early with proof of vaccination.

I certify that I have read, understand, and agree to comply with the provisions listed herein. I acknowledge that failure to act in accordance with the provisions listed herein, or with any other policy or procedure outlined by FCTV in response to COVID-19 will result in disciplinary action pursuant to policy established in FCTV rules and regulation.

Please sign your name and initials and date the form below.

Name *

Initials *

Date *

Month

Day

Year