COVID Declaration

DISCLOSURE NOTICE

For the health and safety of our employees, Nextivity is implementing procedures for measuring the temperature of all visitors coming into our facility and inquiring and observing whether any individual attempting to enter a Company facility has any symptoms of COVID-19. Any individual, whether an employee or visitor, whose temperature is measured to indicate a fever, who reports having or is observed to have any such symptoms, or who has recently been in contact with symptomatic individuals will not be permitted to enter the facility.

Nextivity is notifying you that we are collecting the following category of Personal Information: Medical and health information, specifically your body temperature and whether you have or display certain symptoms commonly associated with COVID-19, such as fatigue, cough, sneezing, aches and pains, runny or stuffy nose, sore throat, diarrhea, headaches, or shortness of breath, whether you have recently been in close contact with anyone who has exhibited any of these symptoms, whether you have recently been in contact with anyone who has tested positive for COVID-19, and whether you have recently traveled to a restricted area that is under a Level 2, 3, or 4 Travel Advisory according to the U.S. State Department.

Nextivity will take reasonable measures to keep the above-mentioned collected information confidential. Should Nextivity receive a report that a visitor has tested positive for or is presumed to have COVID-19, they will be asked to provide a list all co-workers, clients, vendors, or guests with whom the visitor may have come into close contact during the 14-day period prior to the positive test or presumption of being positive for COVID-19. It may also become necessary to share this information with local and state health departments to ensure appropriate protocols and guidelines are followed.

SELF DECLARATION FORM

Please ensure that the information answered below is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 symptoms.

First Name *

Last Name *

Company Name *

Reason for Visiting *

1. Have you been tested positive for COVID-19 in the past 14 days?YesNo

2. Have you traveled out of state in the last 14 days? *YesNo

If the answer above was “yes”, list the area(s) you have traveled below:

3. Have you experienced any of the signs/symptoms of COVID-19 (fatigue, cough, sneezing, aches and pains, runny or stuffy nose, sore throat, diarrhea, headaches, or shortness of breath) in the last 14 days? *YesNo

4. Have you been in contact with anyone that has tested positive for COVID-19 or has knowingly been near someone infected with COVID-19 in the last 14 days? *YesNo

If the answer above was “yes”, list the relationship with the people and your last contact with them:

Type your Full Name and Date to acknowledge and confirm that you have read and understand this disclosure.

Full Name *

Date *