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

FCTV remains committed to providing a safe and welcoming environment. Faciitating video production work during COVID-19 necessitates that we institute protocols including requiring anyone entering to sign our COVID-19 Policy Acknowledgement & Health Attestation form before being allowed entry to the Falmouth Community Media Center. 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 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.

2 *

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.

3 *

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

4 *

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.

5 *

Immediately upon entry, I agree to clean my hands using the hand sanitizer located at the main entrance. I will wash or sanitize my hands frequently throughout my time at FCTV.

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.)

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