COVID-19 Policy Acknowledgement & Health Attestation (required for facility entry)

FCTV remains committed to providing a safe and welcoming environment. The COVID-19 new normal requires we institute new procedures including requiring anyone entering to sign our COVID-19 Policy Acknowledgement & Health Attestation form before being allowed entry to the Falmouth Community Media Center.

First Name *

Last Name *

Email *

Phone Number *

Please Read

1 *

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

2 *

I understand that I must always wear a CDC compliant face mask while at FCTV. Masks must be clean and free of rips or tears.

3 *

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.

4 *

Upon entering I agree to immediately clean my hands using soap and water or hand sanitizer. I will wash my hands using CDC recommended hand washing procedures throughout the day using warm running water and rubbing with soap for at least 20 seconds or use the hand sanitizer located throughout the facility.

5 *

I understand that outside of work, in order to control my exposure in the community, I will comply with any and all state, county or local stay-at-home orders and will follow any recommendations from the CDC that limits my risk of exposure including wearing a mask in all public areas and remaining 6 feet from all other people.

6 *

The Commonwealth of Massachusetts requires that anyone who has traveled out of state (with the exception of lower risk states) will quarantine for 14 days or produce a negative COVID-19 test result that has been administered up to 72-hours prior to your arrival in Massachusetts. I do certify that I have not traveled out of state beyond those the Commonwealth of MA has recognized as low risk states within the last 14 days. NOTE: Failure to comply may result in a $500 per day fine.

7 *

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 of the symptoms listed in Number 1 above, is advised to self-isolate, quarantine, or has tested positive, or is presumed positive for COVID-19.

8 *

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 your vaccination is complete, please indicate the date.

Month

Day

Year

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