Nanny COVID Level Form

Email: *

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Please describe any other details you wish to share or precautions you are taking: *

Do you or your household members work remotely at home, or leave for work?

Do you have any household members who work in high-risk situations?

Yes

No

Phone Number: *

If eligible - have you received the COVID vaccine?

Yes

No

Do you have any close family members you are socially distancing for? *

Name: *

Would you be willing to adjust your precautions to align with the family's?

Yes

No

Of the three levels, which most accurately reflects your current level of precautions?

Level 1

Level 2

Level 3

Are you socially distancing?

Yes

No

Are you willing to limit your exposure with friends and others?

Yes

No

How many people are in your household?

0-1

1-2

2-3

4+

Do you wear a mask in public?

Yes

No

Above & Beyond Nanny Services, Inc.